+++
Essentials of Diagnosis
++
- Acute tears occur after axial loading combined with rotation.
- Sensation of clicking or catching of the knee with motion.
- Positive joint line tenderness, effusion, and a positive McMurray test are important physical exam findings.
- MRI can help classify location and morphology.
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Meniscal injuries are the most common reason for arthroscopy of the knee. The medial meniscus is more frequently torn than the lateral meniscus because the medial meniscus is securely attached around the entire periphery of the joint capsule, whereas the lateral meniscus has a mobile area where it is not attached. Meniscus injury is rare in childhood, occurs in the late teens, and peaks in the third and fourth decades. After the age of 50, meniscus tears are more often the result of arthritis than trauma.
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Acute traumatic tears of the menisci are often caused by axial loading combined with rotation. Patients typically report pain and swelling. Patients with smaller tears may have a sensation of clicking or catching in the knee. Patients with larger tears in the meniscus may complain of locking of the knee as the meniscus displaces into the joint and/or femoral notch. Loss of knee motion with a block to extension may result from a large bucket-handle tear. In acute tears involving an associated ACL injury, the swelling may be more significant and acute. ACL injuries often involve a lateral meniscus tear as the lateral compartment of the knee subluxates forward trapping the lateral meniscus between the femur and tibia.
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Conversely, chronic or degenerative tears of the menisci often present in older patients (>40 years old) with the history of an insidious onset of pain and swelling with or without an acute increase superimposed. Often, no identifiable history of trauma is obtained, or the inciting event may be quite minor such as a bending or squatting motion.
++
The most important physical examination findings in the knee with a meniscus tear are joint line tenderness and an effusion. Other specialized tests include the McMurray, flexion McMurray, and Apley grind tests. The McMurray test is performed with the patient lying supine with the hip and knee flexed to about 90 degrees. While one hand holds the foot and twists it from external to internal rotation, the other hand holds the knee and applies compression (Figure 3–12). A positive test is one that elicits a pop or click that can be felt by the examiner when the torn meniscus is trapped between the femoral condyle and tibial plateau. A variation of this test is the flexion McMurray, in which the knee is held as for the McMurray test. To test the medial meniscus, the foot is externally rotated and the knee maximally flexed. A positive test occurs when the patient experiences pain over the posteromedial joint line as the knee is gradually extended. The Apley grind test requires placing the patient prone with the knee flexed to 90 degrees. The examiner applies downward pressure to the sole of the foot while twisting the lower leg in external and internal rotation. A positive test results in pain at either joint line.
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In addition to the above, physical examination of the entire leg is essential. Assessing hip range of motion and irritability is useful, especially in children, as referred pain from the hip to the knee area is common. Examining for quadriceps atrophy and the presence of a knee effusion should also be done. Measurement of range of motion may reveal a loss of the normal knee extension. Assessing for tenderness of the femoral condyles, joint lines, tibial plateaus, and patellofemoral joint may give clues as to a possible osteochondral lesion, meniscus lesion, fracture, or chondrosis, respectively. Ligamentous testing including varus and valgus stress testing at full extension and 30 degrees of flexion and Lachman, anterior drawer, and posterior drawer testing should be done to assess stability.
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Meniscal tears can be classified either by etiology or by their arthroscopic and MRI appearance. Etiologic classification divides tears into either acute tears (excessive force applied to an otherwise normal meniscus) or degenerative tears (normal force applied to a degenerative structure).
++
Classification should describe the tear location and its associated vascularity, morphology, and stability. Tear location is described by its location in the anteroposterior plane (anterior, middle, or posterior) and its circumferential location with respect to its vascularity. The common vascular zones include the most peripheral red/red zone near the meniscocapsular junction, the intermediate red/white zone, and the most central white/white zone. As tears occur more centrally, the healing rate is lower because of a decreased blood supply. Tears can also occur at the meniscal root, which is the attachment of the meniscus to the tibia.
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Tear morphology describes the orientation of the tear within the meniscus and includes vertical or horizontal longitudinal, radial (transverse), oblique, and complex (including degenerative) tears (Figure 3–13). Most acute tears in younger patients are vertical longitudinal or oblique tears, while complex and degenerative tears occur more commonly in older patients. Vertical longitudinal, or bucket-handle tears, can be complete or incomplete and usually start in the posterior horn and continue anteriorly a variable distance. Large tears can cause significant mobility of the torn meniscal fragment, allowing it to displace into the femoral notch and cause a locked knee (Figure 3–14). This more commonly occurs in the medial meniscus, possibly owing to its decreased mobility. Oblique tears commonly occur at the junction of the middle and posterior thirds. They are often smaller tears, but the free edge of the tear can catch in the joint and cause symptoms of catching. Complex or degenerative tears occur in multiple planes, are often located in or near the posterior horns, and are more common in older patients with degenerative menisci. Horizontal longitudinal tears are often associated with meniscal cysts. They usually start at the inner margin of the meniscus and extend toward the meniscocapsular junction. They are thought to result from shear stresses and, when associated with meniscal cysts, occur in the medial meniscus and cause localized swelling at the joint line.
++
++
+++
Treatment and Prognosis
++
Small stable meniscus tears often become asymptomatic and do not need to be treated surgically. Those causing persistent symptoms should be assessed with the arthroscope. Before the importance of the meniscus was understood and arthroscopy became available, the meniscus was often removed, even when normal. We now attempt to remove only the torn portion of the meniscus or repair the meniscus, if possible.
++
During arthroscopy, the meniscus can be visualized and palpated with a probe. The inner two thirds of the meniscus is avascular and often requires resection when torn. The remaining meniscus is smoothed and contoured to prevent further tearing from a jagged edge. Return to full function may be expected in 6–8 weeks.
++
Tears in the peripheral third of the meniscus, if small (<15 mm), may heal spontaneously because there is a blood supply in this portion of the adult meniscus. Larger tears need to be repaired because those who undergo meniscectomy at a young age are at risk of early osteoarthritis. These changes were first described by Fairbanks and include flattening of the femoral condyle, joint space narrowing, and osteophyte formation. Therefore, every effort should be made to preserve the meniscus.
+++
Partial Meniscal Resection
++
Partial meniscectomy has a 90% rate of good or excellent results in patients without knee instability or osteoarthritis. A major advantage over meniscus repair is a short recovery period. However, results diminish over time, and osteoarthritis occurs with over 10 years of follow-up. Medial meniscus tears generally do better than lateral tears after partial resection, and an intact meniscal rim and those with normal articular cartilage and normal knee stability are associated with a better prognosis.
++
Most surgeons will attempt a meniscus repair rather than a partial meniscectomy in young, active individuals. Other commonly accepted criteria for meniscus repair include a complete vertical longitudinal tear greater than 15 mm in length, a tear within the peripheral 10–30% of the meniscus (ie, within 3–4 mm of the meniscocapsular junction), a peripheral tear that can be displaced toward the center of the plateau with a probe, the absence of secondary meniscus degeneration, and a tear in a patient undergoing concurrent ligament or articular cartilage repair.
++
Multiple factors affect the success of meniscus repair. Although no absolute age limit exists, patients younger than 40 years are thought to have a better chance for healing. Knees with associated ligamentous instability, particularly ACL instability, have inferior rates of meniscus healing because of abnormal meniscus stresses from tibiofemoral instability. The location of the tear and the time lapsed from injury to treatment are also important. Acute tears located in the peripheral red/red or red/white zone have better healing capability than chronic tears located in the red/white or white/white zones. Tears 5 mm or more from the periphery are considered avascular (white zone), whereas those between 3 and 5 mm are variable in vascularity (red/white), and tears in the peripheral 3 mm are considered vascular (red). In areas with marginal vascularization, abrasion of the meniscocapsular junction or use of a fibrin clot may be performed. It is thought that a vascular pannus forms from the abraded tissue that aids in healing. Finally, the stability of the meniscus repair is a factor, with vertical mattress sutures generally considered the gold standard in meniscus repair. It is generally believed that the superiority of vertical mattress over horizontal mattress sutures is from the vertical mattress sutures capturing the strong peripheral, circumferential fibers of the meniscus.
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Meniscus repair is more successful when done at the same time as ACL reconstruction. Then it is successful up to 90% of the time compared to approximately 50% success in patients with intact ACLs who had meniscus repairs. Many of the meniscus tears that occur with an ACL tear are amenable to repair. Then stabilizing the knee with ACL reconstruction protects the repaired meniscus from abnormal knee motion and has more success than if the knee is left unstable.
++
Types of repairs include the traditional open repair and arthroscopic repairs that can be done with inside-out, outside-in, or all-inside techniques. Inside-out and outside-in repairs are usually done with sutures and require a mini-incision and securing of the meniscus to the capsule with sutures. The all-inside technique has many device options, including sutures and various devices. Regardless of the type of repair chosen, adequate preparation of the tear site is required. The tear edges should be debrided or abraded with a shaver or rasp to stimulate bleeding. Restoration of biomechanical function is encouraged by anatomic apposition of the tear edges to ensure good healing potential.
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Open repair of meniscus tears has been shown to have successful long-term results. The technique involves making a small incision through the subcutaneous tissue, capsule, and synovium to directly visualize the tear. Open repair is most useful in peripheral or meniscocapsular tears, often occurring in conjunction with open repair of a collateral ligament injury or a tibial plateau fracture. Follow-up studies of 10 years or longer have shown survival rates of repaired menisci of 80–90%, in part influenced by the peripheral nature of the tear and the associated hemarthrosis present in ligament tears or fracture repair cases.
+++
Arthroscopic Meniscal Repair
+++
Inside-Out Meniscal Repair
++
Arthroscopic inside-out meniscus repairs are performed using long needles introduced through cannula systems with attached absorbable or nonabsorbable sutures passed perpendicularly across the tear from inside the knee to a protected area outside the joint capsule. These sutures are able to obtain consistent perpendicular placement across the meniscus tear, which gives this method an advantage over other repair techniques. Improved suture placement is gained at the expense of possible neurovascular injury from passing the needle from inside the knee to outside the joint. This technique requires a posteromedial or posterolateral incision to protect the neurovascular structures and safely retrieve the exiting needles. Because surgeons are able to place vertical mattress sutures, the best biomechanical construct for meniscus repair, this technique remains the gold standard for many surgeons. Numerous retrospective and prospective studies using second-look arthroscopy or arthrography to evaluate healing of the meniscus repairs have consistently shown rates of 70–90% in isolated repairs, and greater than 90% when done in conjunction with an ACL reconstruction. This technique is ideal for posterior and mid-posterior horn tears. There is difficulty in passing needles in mid to anterior horn meniscus tears.
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Outside‐in Meniscal Repair
++
The arthroscopic outside-in repair was developed in part to decrease the neurovascular risk associated with the inside-out technique. The outside-in technique involves passing a needle from outside the joint, across the tear, and into the joint. Two options then exist for repair of the meniscus tear. One option is then to retrieve the suture through an anterior portal, tie a knot outside the knee joint, and then bring the knot back in through the anterior portal placing the knot against the reduced meniscus body fragment. A second option is to use parallel needles and retrieve the suture through the second needle. This can be done using a suture relay. A knot is then tied outside the joint over the capsule. This method is useful for tears in the anterior horn or body of the menisci, but does not work for tears in or near the posterior horn. Results of the outside-in technique using MRI, arthrography, or second-look arthroscopy to assess healing have shown complete or partial healing; between 74% and 87% of meniscus repairs have been successful. As expected, more posterior horn tears and tears in unstable knees did worse.
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All-Inside Meniscal Repair
++
The popularity of the all-inside repairs has increased with the introduction of numerous devices and techniques to ease the technique. They do not require accessory incisions, thereby saving operative time, and they avoid more technical arthroscopic techniques required in other types of repairs. However, repairs with some devices have not been as successful as those with traditional techniques. Success rate is 60–90%, and some have found results comparable to traditional techniques, but there are complications including devices that have migrated from their original position, broken fragments, foreign-body reactions, inflammation, chronic effusions, and articular cartilage injuries.
++
Recent biomechanical studies have found repair with some of these devices to have properties equivalent to vertical mattress sutures. But there is considerable variation with the type of device. What remains to be known, however, is the meniscus repair strength needed for optimal meniscus healing.
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Meniscal Transplantation
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An alternative to leaving the patient with a meniscus-deficient knee, and almost certain early osteoarthrosis, is meniscus transplantation. This technique yields satisfactory results in about two thirds of patients. In the future, biologic scaffolds may enable menisci to be regenerated after meniscectomy.
Ahn JH, Wang JH, Yoo JC: Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament–deficient knees: results of second-look arthroscopies in 39 cases.
Arthroscopy 2004;20:936.
[PubMed: 15525926]
Hommen JP, Applegate GR, Del Pizzo W: Meniscus allograft transplantation: ten-year results of cryopreserved allografts.
Arthroscopy 2007;23:388.
[PubMed: 17418331]
Metcalf MH, Barrett GR: Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees.
Am J Sports Med 2004;32:675.
[PubMed: 15090384]
Salata MJ, Gibbs AE, Sekiya JK: A systematic review of clinical outcomes in patients undergoing meniscectomy.
Am J Sports Med 2010;38:1907.
[PubMed: 20587698]
Shelbourne KD, Dersam MD: Comparison of partial meniscectomy versus meniscus repair for bucket-handle lateral meniscus tears in anterior cruciate ligament reconstructed knees.
Arthroscopy 2004;20:581.
[PubMed: 15241307]
Steenbrugge F, Verstraete K, Verdonk R: Magnetic resonance imaging of the surgically repaired meniscus: a 13-year follow-up study of 13 knees.
Acta Orthop Scand 2004;75:323.
[PubMed: 15260425]
Stone KR, Adelson WS, Pelsis JR, Walgenbach AW, Turek TJ: Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage: a prospective two- to 12-year follow-up report.
J Bone Joint Surg Br 2010;92:941.
[PubMed: 20595111]
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CPT Codes for the Meniscus
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- 27403 Arthrotomy with meniscus repair, knee
- 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
- 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
- 29880 Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving)
- 29881 Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving)
- 29882 Arthroscopy, knee, surgical; with meniscus repair (medial or lateral)
- 29883 Arthroscopy, knee, surgical; with meniscus repair (medial and lateral)
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Articular cartilage injuries of the knee are infrequent, and there must be a high index of suspicion to detect them. MRI and arthroscopy are very helpful with these injuries, especially pure articular cartilage injuries, where radiographs will be normal.
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Osteochondral Lesions
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Essentials of Diagnosis
++
- Patients usually present with vague, poorly localized complaints of knee pain.
- Classic location is the posterolateral aspect of the medial femoral condyle.
- Involvement is bilateral in up to 25% of cases, so examine both knees.
- Effusion, crepitus, and an antalgic gait are possible findings on exam.
- Radiographs and MRI can be helpful in determining the location and size of the lesion.
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Osteochondral Fracture
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There is much confusion about the nomenclature and etiology of juvenile and adult osteochondral lesions (OCL) of the knee, also called osteochondritis dissecans. Inflammatory, ossification abnormalities and avascular necrosis have all been considered etiologies of this condition. However, basic science, histopathology, and vascular studies do not support any of them. The term “osteochondral injuries” has been used to describe injuries ranging from acute osteochondral fractures to pure chondral injuries. Currently, OCLs are defined as potentially reversible idiopathic lesions of subchondral bone, resulting in delamination or fragmentation with or without destruction of the overlying articular cartilage. OCLs are subdivided into juvenile and adult forms depending on the presence of an open distal femoral physis. In children, a combination of etiologies is now thought to be responsible for OCLs. For example, a stress fracture may develop in the subchondral bone of the distal femoral condyle. Such an injury may provoke further vascular compromise, which results in injury to the subchondral bone that was initially covered with normal articular cartilage. Loss of support from the subchondral bone may result in damage to the overlying articular cartilage. The vast majority of adult OCLs are thought to have arisen from a persistent juvenile OCL, although new lesions in adults are possible as well.
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Both adult and juvenile OCLs that do not heal have the potential for further sequelae, including degenerative osteoarthritis. Juvenile OCLs, defined as knees with an open physes, generally have a better prognosis than adult lesions. The classic location of an OCL is the posterolateral aspect of the medial femoral condyle, which accounts for 70–80% of all OCLs. Lateral condyle OCLs are seen in 15–20% of patients, and patellar involvement ranges from 5–10%. The increased use of MRI and arthroscopy over the past decade may have resulted in greater recognition of OCLs.
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A common presentation of a patient with an OCL is aching and activity-related anterior knee pain that is poorly localized. Pain may worsen with stair climbing or running. Patients with stable OCLs do not have mechanical symptoms or knee instability. Mechanical symptoms are more common in patients with unstable or loose OCLs. Patients may limp, and knee swelling may be present. Tenderness with palpation of the femoral condyle may be observed with various degrees of knee flexion. Loss of range of motion or quadriceps atrophy may be noted in more long-standing cases.
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It is important to identify patients with unstable lesions. There may be crepitus and pain with range of motion, and an effusion is typically present. Involvement is bilateral in up to 25% of cases, so both knees should be evaluated regardless of symptoms. Initial evaluation should include anteroposterior, lateral, and tunnel views of both knees. The goal of plain radiographs is to exclude any bony pathology, evaluate the physes, and localize the lesion. Lesion location and an estimation of size can be determined as described by Cahill. MRI may be helpful in diagnosis and can give an estimation of the size of the lesion (prognosis is better for small lesions), the condition of the overlying cartilage and underlying subchondral bone, the extent of bone edema, the presence of any loose bodies, and assessment of OCL stability. Four MRI criteria have been identified on T2-weighted images to assess OCL stability: a line of high signal intensity at least 5 mm in length between the OCL and underlying bone, an area of increased homogeneous signal at least 5 mm in diameter beneath the lesion, a focal defect of 5 mm or more in the articular surface, and a high signal line traversing the subchondral plate into the lesion. A high signal line is the most common sign in patients found to have unstable lesions that are most likely to fail nonoperative treatment. MRI is helpful with these injuries, especially pure articular cartilage injuries, where radiographs will be normal or may result in false-positive findings of fragment loosening. Arthroscopy remains the gold standard in evaluation of these lesions.
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Equivocal prognostic value has been found in the use of intravenous gadolinium in OCLs. Technetium bone scans were initially proposed to monitor the presence of healing. However, because MRI eliminates the ionizing radiation and increased time required in bone scanning, bone scanning is not widely used.
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Treatment and Prognosis
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Prognosis is good for the immature child. Nonoperative management should be pursued in those with a stable OCL and open physes. The goal of nonoperative treatment is to obtain a healed lesion before physis closure so as to prevent early-onset osteoarthritis. Even if patients are within 6–12 months of physeal closure, a trial of nonoperative treatment is warranted.
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Because failure of the subchondral bone precedes failure of the overlying articular cartilage, most orthopedists recommend some sort of activity modification. Debate exists whether activity modification should include the use of cast or brace immobilization. The tenet of nonoperative treatment is to reduce the activity level where pain-free activities of daily living are possible. However, there is no optimal immobilization protocol available in the literature.
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Patients should be non–weight bearing or partial weight bearing with crutches for 3–6 weeks or until they are pain free. Repeat radiographs are obtained at approximately 6-week intervals. Physical therapy with full weight bearing may be initiated once patients are pain free. Physical therapy should focus on low-impact quadriceps and hamstring strengthening. If patients remain asymptomatic up to at least 3 months after the diagnosis was made, activity may be slowly advanced to higher impact activities such as running or jumping. Any recurrence of symptoms or any progression of the OCL on plain radiographs should prompt a return to non–weight bearing and possible immobilization for a longer period. Obvious patient frustration and lack of compliance (especially in adolescents) is common, and a full discussion of the risks and benefits of nonoperative or operative treatment is required.
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Operative treatment should be considered in the following instances: (1) loose bodies, (2) an unstable OCL, (3) persistence of symptoms despite nonoperative treatment in a compliant patient, (4) worsening appearance on imaging studies, and (5) near or complete epiphyseal closure. Goals of operative treatment should include achievement of a stable osteochondral fragment that maintains joint congruity and allows early range of motion.
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For stable lesions with an intact articular surface, arthroscopic drilling of the lesions is preferred. This creates channels for potential revascularization through the subchondral bone plate. Options include transarticular drilling and transepiphyseal drilling. Radiographic healing and relief of symptoms can be expected in 80–90% of patients with open physes. This decreases to 50–75% in those with closed physes.
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Patients with partially unstable lesions such as a flap lesion should be managed by the status of the subchondral bone. If present, fibrous tissue between the lesion and subchondral bone should be debrided. If significant subchondral bone loss has occurred, it can be filled with autogenous bone graft prior to fixation of the OCL. If the OCL has sufficient bone such that an anatomic fit into its donor site is possible, fixation should be attempted. Various fixation methods have been described including Herbert or cannulated screws and bioabsorbable screws or pins, but there are complications with these treatments. Complications include devices that have migrated from their original position, broken fragments, foreign-body reactions, inflammation, chronic effusions, and articular cartilage injuries.
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Simple excision of the larger fragments has shown poor results with more rapid progression of radiographic osteoarthritic changes. For lesions greater than 2 cm2, drilling or microfracture methods that depend on replacement of the defect with fibrocartilage have yielded poor results with worsening osteoarthritis over time. For these larger lesions, cartilage transplantation has been tried. Disadvantages of autologous osteochondral plugs or mosaicplasty include donor site morbidity and incongruent articular fit. Advantages include good fixation of the patient's own tissue. Another option is autologous chondrocyte implantation, which involves harvesting of the patient's chondrocytes, proliferating them over time, and then reimplanting the chondrocytes. Advantages include use of the patient's own tissue and lessened donor site morbidity. Longer-term results in young adult patients show successful clinical results in up to 90% for both procedures. However, additional larger and longer-term follow-up studies are needed.
Cepero S, Ullot R, Sastre S: Osteochondritis of the femoral condyles in children and adolescents: our experience over the last 28 years.
J Pediatr Orthop B 2005;14:24.
[PubMed: 15577303]
Crawford DC, Safran MR: Osteochondritis dissecans of the knee.
J Am Acad Orthop Surg 2006;14:90.
[PubMed: 16467184]
Detterline AJ, Goldstein JL, Rue JP, et al: Evaluation and treatment of osteochondritis dissecans lesions of the knee.
J Knee Surg 2008;21:106.
[PubMed: 18500061]
Gomoll AH, Farr J, Gillogly SD, Kercher J, Minas T: Surgical management of articular cartilage defects of the knee.
J Bone Joint Surg Am 2010;92:2470.
[PubMed: 20962200]
Vasiliadis HS, Wasiak J: Autologous chondrocyte implantation for full thickness articular cartilage defects of the knee.
Cochrane Database Syst Rev 2010;10:CD003323.
[PubMed: 20927732]
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CPT Codes for Osteochondral Lesions
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- 27415 Osteochondral allograft, knee, open
- 29850 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)
- 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])
- 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)
- 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
- 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
- 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
- 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)
- 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion
- 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation
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Knee injuries occur during both contact and noncontact athletic activities. Advances in the diagnosis and treatment of ligament injuries have allowed athletes at all levels of ability to return to sports at their preinjury level of activity. The ligaments and menisci of the knee work in concert with one another, and frequently more than one structure is damaged when an acute injury occurs.
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Ligament injuries are graded as follows: grade 1, stretching of the ligament with no detectable instability; grade 2, further stretching of the ligament with detectable instability, but with the fibers in continuity; and grade 3, complete disruption of the ligament.
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Knee stability requires proper functioning of four ligaments. These ligaments include the ACL, the PCL, the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). There are also several accessory or secondary stabilizers of the knee. Secondary stabilizers of the knee include the menisci, iliotibial band, and biceps femoris. These secondary stabilizers become more important when a primary stabilizer is injured.
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The MCL is the primary static stabilizer against valgus stress at the knee. The MCL originates from the central sulcus of the medial epicondyle. The sulcus of the C-shaped medial epicondyle is located anterior and distal to the adductor tubercle. The MCL is made up of three main static medial stabilizers of the knee. This includes the superficial MCL, the posterior oblique ligament, and the deep capsular ligament.
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The LCL is the primary static stabilizer against varus stress at the knee. The LCL originates from the lateral epicondyle. This is the most prominent point of the lateral femoral condyle. The LCL insertion is on the styloid process of the fibular head, which projects superiorly from the posterolateral fibular head. The LCL joins with the arcuate ligament, the popliteus muscle, and the lateral head of the gastrocnemius to form a lateral arcuate complex to control statically and dynamically varus angulation and external tibial torsion. The iliotibial band and biceps femoris also contribute to stability on the lateral aspect of the knee.
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The ACL is the primary static stabilizer of the knee against anterior translation of the tibia with respect to the femur. The ACL originates from the posteromedial surface of the lateral femoral condyle in the intercondylar notch. The ACL inserts on the tibial plateau just medial to the anterior horn of the lateral meniscus about 15 mm posterior to the anterior edge of the tibial articular surface. The blood supply to the ACL and PCL is the middle geniculate artery. Both the ACL and PCL are covered by a layer of synovium, making these ligaments intraarticular and extrasynovial.
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The PCL is the primary static stabilizer of the knee against posterior translation of the tibia with respect to the femur. The PCL originates from the posterior aspect of the lateral surface of the medial femoral condyle in the intercondylar notch. The PCL inserts on the posterior aspect of the tibial plateau in a central depression just posterior to the articular surface. The insertion extends distally along the posterior aspect of the tibia for up to 1 cm in length. The PCL is a complex structure consisting of two major bands: the anterolateral and posteromedial bands. The anterolateral band is tight in flexion and loose in extension. The posteromedial band is loose in flexion and tight in extension. The cross-sectional area of the anterolateral band is twice as large as the posteromedial band. The meniscofemoral ligaments, the ligaments of Wrisberg and Humphrey, are the third component of the PCL. The meniscofemoral ligaments travel from the posterior horn of the lateral meniscus to the posteromedial femoral condyle.
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Differential Diagnosis of Knee Instability
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The differential diagnosis of acute or chronic knee instability can involve any of the knee ligaments and/or the structures of the posterolateral corner. There are often combinations of ligament injuries in addition to injuries of secondary stabilizing structures such as the menisci. The history and mechanism of injury are valuable information, if available. Similarly, the location of pain can help to narrow the diagnosis. Clearly, however, a thorough physical examination helps to distinguish which ligaments have been injured. Additionally, imaging studies are often obtained to confirm clinical suspicions and to evaluate for occult injuries.
Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: evaluation, treatment and results.
Arthroscopy 2005;21:471.
[PubMed: 15800529]
Micheo W, Hernández L, Seda C: Evaluation, management, rehabilitation, and prevention of anterior cruciate ligament injury: current concepts.
PM R 2010;2:935.
[PubMed: 20970763]
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Medial Collateral Ligament Injuries
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Essential of Diagnosis
++
- Occurs after a valgus stress to the knee or noncontact rotational injury.
- Medial knee pain and instability at 30 degrees of flexion is diagnostic; consider ACL or PCL injuries in addition if opening at full extension with a valgus stress.
- Chronic injuries may have calcification at the insertion of the MCL on the medial femoral condyle.
- MRI can be helpful in confirming diagnosis and helping to rule out concomitant meniscal injury.
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How and when the patient was hurt are important parts of the history. Lower-grade MCL injuries typically occur in a noncontact external rotational injury, whereas higher-grade injuries generally involve lateral contact to the thigh or upper leg. Other important pieces of historical information include the location and presence of pain, instability, timing of swelling, and sensation of a “pop” or tear. Surprisingly, grade I and II injuries are often more painful than complete MCL rupture. Immediate swelling should make one suspicious for an associated cruciate ligament injury, fracture, and/or patellar dislocation.
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A prior history of knee injuries or instability should always be sought when evaluating a new knee injury.
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Signs (Physical Examination)
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MCL injuries are evaluated with a complete knee examination to evaluate for any other coexisting injuries. This is especially true with ACL and PCL evaluation because an injury to either of these ligaments would significantly change the treatment. Given the frequency of coexisting patellar dislocations in MCL injuries, palpation of the patella and the medial parapatellar stabilizing ligaments should be performed in addition to patellar apprehension testing.
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Medial joint line tenderness along the course of the MCL is typical at the location of the tear. Laxity to valgus stresses is assessed by the amount of medial joint space opening that occurs at 30 degrees of flexion. It is important to stress the knee at 30 degrees of flexion because with the knee in full extension the posterior capsule and PCL will stabilize the knee to valgus stress. This stability to valgus stress in full extension could mislead the examiner to believe that the MCL is intact. Zero opening is considered normal, with 1-4 mm indicating a grade I injury, 5–9 mm indicating a grade II injury, and 10–15 mm indicating a complete or grade III injury. Additionally, grade I and II injuries typically have a firm end point, whereas a grade III injury tends to have a soft end point to valgus stress.
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A series of knee radiographs should be obtained in any patient with a suspected significant knee injury. Radiographs should be inspected for acute fracture, lateral capsular avulsion (Segond fracture; see section on ACL imaging), loose bodies, Pellegrini-Stieda lesion (MCL calcification), and evidence of patellar dislocation. Stress radiographs should be obtained in patients prior to skeletal maturity to rule out an epiphyseal fracture.
++
MRI is useful for confirming MCL injury and identifying the site of injury. It is also useful to detect the presence of meniscal and other injuries to the knee. Relative indications for an MRI include an uncertain ACL status despite multiple examinations, evaluation of a suspected meniscal tear, or preoperative evaluation for a planned MCL reconstruction or repair.
++
An examination under anesthesia can be valuable when physical examination is unreliable because of the patient guarding the knee. Diagnostic arthroscopy can also be used to evaluate for coexistant pathology. However, both of these diagnostic methods have largely been replaced by MRI.
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Treatment (Nonsurgical and Surgical)
++
Treatment of an isolated MCL injury is generally nonoperative with protection against valgus stress and early motion. Grade I and grade II injuries can be placed in either a cast or a brace and bear weight as tolerated. Generally, knee motion is started within the first week or two, and full recovery is usually achieved more rapidly with early knee range of motion.
++
Grade III injuries are a bit more controversial. Several authors have shown increased instability in grade III tears treated nonsurgically, although most of these studies did not exclude knees with multiligamentous injuries. Comparison of isolated grade III MCL tears treated with surgical reconstruction versus nonsurgical management showed that the nonsurgical treatment group enjoyed better results in both subjective scoring and earlier return to activity.
++
The exception to the current trend of nonsurgical treatment of grade III injuries is in the setting of a multiligamentous knee injury. In this setting, particularly with a distal tibial avulsion of the MCL, nonsurgical treatment has not fared nearly as well as in isolated MCL injuries. MCL repair in the acute setting can include a primary repair, with shortening if needed, of the torn ligament. Similarly, avulsion fragments are treated with reduction and fixation in the acute setting. Primary repairs can be reinforced with autograft or allograft tissues if the remaining MCL is insufficient for a stand-alone repair. Chronic reconstructions also often include autograft or allograft tissue reconstruction.
++
Traditionally, casting or operative treatment of MCL injuries significantly limited an early return to range-of-motion exercises. With the addition of functional bracing and early motion to a nonsurgical treatment protocol, motion and strengthening of the knee can occur at an early stage while the ligament is protected from valgus stress. As knee motion improves, isotonic strengthening exercises are introduced. As the strength of the extremity improves, the intensity of functional rehabilitation increases accordingly.
++
With nonsurgical treatment becoming the standard of care, complications associated with an MCL injury have decreased. The main complication of nonsurgical therapy is residual valgus laxity or medial knee pain. Radiographs may show residual calcification of the MCL (Pellegrini-Stieda lesion). Potential surgical complications include arthrofibrosis, infection, damage to the saphenous nerve or vein, or recurrent valgus laxity.
+++
Results/Return to Play
++
In general, good outcomes can be achieved with nonsurgical treatment and rehabilitation of isolated MCL injuries. Return to professional football after nonsurgical treatment of isolated MCL injuries is 98%.
Azar FM: Evaluation and treatment of chronic medial collateral ligament injuries of the knee.
Sports Med Arthrosc 2006;14:84.
[PubMed: 17135952]
Robinson JR, Bull A, Thomas R, et al: The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity.
Am J Sports Med 2006;34:1815.
[PubMed: 16816148]
Robinson JR, Sanchez-Ballester J, Bull AM, et al: The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee.
J Bone Joint Surg Br 2004;86:674.
[PubMed: 15274262]
Stannard JP: Medial and posteromedial instability of the knee: evaluation, treatment, and results.
Sports Med Arthrosc 2010; 18:263.
[PubMed: 21079506]
+++
Lateral Collateral Ligament Injuries
+++
Essentials of Diagnosis
++
- Patients may complain of lateral knee pain and a varus thrust with daily activity.
- Varus stress to the knee with opening at 30 degrees of flexion is diagnostic for an isolated LCL injury.
- Frequently part of a multiligamentous injury to the knee.
- There is a high incidence of peroneal nerve injury; document neurovascular status to the involved extremity.
- MRI should be obtained as a useful adjunct to help diagnose posterolateral corner injuries.
++
The most consistent symptom of an acute LCL injury is lateral knee pain. However, the symptoms of lateral and posterolateral instability are quite variable and depend on the severity of injury, patient activity level, overall limb alignment, and other associated knee injuries. For example, a sedentary individual with minimal laxity and overall valgus alignment will have few, if any, symptoms. However, if LCL laxity is combined with overall varus alignment, hyperextension, and an increased activity level, symptoms will be quite pronounced. These patients may complain of lateral joint line pain and a varus thrust of their leg with everyday activities. This is often described as the knee buckling into hyperextension with normal gait.
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Signs (Physical Examination)
++
Patients with an LCL and/or posterolateral corner injury often also have additional ligamentous injuries to the knee. Therefore, a thorough knee examination should be performed to evaluate for coexistant knee pathology. Additionally, a careful neurovascular examination should be performed as the incidence of neurovascular injury, particularly peroneal nerve injury, has been reported in 12–29% of posterolateral knee injuries.
++
The integrity of the LCL is assessed by placing a varus stress, with the knee in full extension and 30 degrees of flexion. Baseline varus opening is widely variable and should be compared to the contralateral leg. The average baseline for varus opening is 7 degrees. Exam findings with an isolated LCL injury should include varus laxity at 30 degrees of flexion and no instability in full extension. This is due to the stabilizing effect that the intact cruciate ligaments provide in full extension.
++
It is important to note that a significant posterolateral knee injury can be present without significant varus laxity. The most useful test to evaluate for posterolateral instability is the dial test. This is done by externally rotating each tibia and noting the angle subtended between the thigh and the foot. The dial test is performed at 30 and 90 degrees of flexion with a significant difference being an angle 5 degrees or greater than the contralateral leg. Injury to the posterolateral capsule alone is confirmed with greater external rotation at 30 degrees, an isolated PCL at 90 degrees, and to both structures when there is greater rotation at 30 and 90 degrees compared to the uninjured leg.
++
A series of knee radiographs should be obtained in any patient with a suspected knee injury. Radiographs should be inspected for acute fractures, lateral capsular avulsion (Segond fracture; see section on ACL imaging), loose bodies, fibular head avulsions, and evidence of patellar dislocation. With chronic posterolateral instability, degenerative changes of the lateral compartment are often noted. Lateral joint space narrowing with osteophytes and subchondral sclerosis can be seen. Stress radiographs can help to better quantify the amount of varus angulation present.
++
MRI is often a useful adjunct for diagnosing posterolateral corner and LCL injuries in the severely injured knee. As mentioned earlier, this posterolateral injury can often go unnoticed during an initial evaluation, and MRI findings can refocus the examination to the posterolateral structures. Pain and guarding at the time of injury can often obscure posterolateral injury, and MRI can prove to be an extremely valuable adjunct in diagnosis.
+++
Special Tests/Examinations
+++
Reverse Pivot Shift Test
++
This test involves starting with the knee flexed to 90 degrees. While the knee is extended, the leg is loaded axially with a valgus stress applied to the knee and the foot is held in external rotation. A palpable shift is noted as the tibia reduces from its posteriorly subluxed position as the knee is extended.
+++
External Rotation Recurvatum Test
++
This test is performed with the patient supine and the hip and knee fully extended. The leg is lifted off the bed by the toes. Hyperextension, varus instability, and external rotation of the tibial tubercle occurs with adequate quadriceps relaxation in a patient with posterolateral instability.
+++
Posterolateral Drawer Test
++
A standard posterior drawer test (see section on PCL physical examination) is performed with the tibia in internal rotation, neutral, and externally rotated positions. With posterolateral injury, the magnitude of the posterior drawer displacement will be greatest with external tibial rotation.
+++
Examination under Anesthesia
++
An examination while the patient is relaxed under general anesthetic is extremely useful, particularly in the acute setting. If the patient with a multiligamentous knee injury is taken to the operating room, this is an excellent opportunity to examine the knee without guarding to improve the accuracy of the examination.
++
Isolated LCL ligament injuries, as noted earlier, are rare injuries. However, in the case of an isolated LCL ligament injury with grade II or less magnitude, a period of immobilization from 2–4 weeks followed by a quadriceps strengthening program will usually yield good results. Grade III injuries often have better results with surgical treatment. The combination of delayed diagnosis along with an uncertain natural history of posterolateral instability makes the treatment of these injuries a challenge.
++
LCL and posterolateral ligament injuries, as discussed earlier, rarely occur in isolation. Therefore, other injuries must also be considered in the treatment plan of the multiligamentous knee injury. Ideally, the posterolateral and LCL injuries are diagnosed in the acute setting. This allows the preferred surgical treatment of a primary repair of the injured structures with augmentation as needed. Primary repair is generally only feasible in the first few weeks following the knee injury.
++
The knee with chronic posterolateral instability will often require ligamentous reconstruction or advancement to reconstitute a static restraint to varus stresses. The key biomechanical concept of any lateral ligamentous reconstruction is that the isometric point of the LCL lies between the fibular head and the lateral epicondyle. Therefore, regardless of the graft material used to reconstruct the lateral ligamentous complex, a portion of the graft must pass between the lateral femoral epicondyle and the fibular head.
++
To improve the success rate of reconstruction of chronic lateral ligamentous instability, a proximal tibial valgus osteotomy may be performed to decrease the stress on the lateral structures of the knee.
++
The rehabilitation of the knee after posterolateral reconstructions or repairs is largely guided by associated injuries to the ACL or PCL. It is generally necessary, however, to limit weight bearing for at least 6 weeks and protect the lateral structures with a brace for at least 3 months.
++
The peroneal nerve runs just posterior to the fibular head. It is important to isolate the peroneal nerve prior to any lateral knee exposure to minimize the complication of a peroneal nerve injury.
++
If injuries to the posterolateral corner of the knee are diagnosed and repaired acutely, the results are good for restoration of varus stability and return to play. Chronic posterolateral corner injury reconstructions also perform well when an isometric lateral reconstruction is achieved.
Laprade RF, Engebretsen L, Johansen S, et al: The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability.
Am J Sports Med 2008;36:956.
[PubMed: 18227230]
Markolf KL, Graves BR, Sigward SM, et al: Effects of posterolateral reconstructions on external tibial rotation and forces in a posterior cruciate ligament graft.
Bone Joint Surg Am 2007;89:2351.
[PubMed: 17974876]
Ranawat A, Baker C 3rd, Henry S, et al: Posterolateral corner injury of the knee: evaluation and management.
J Am Acad Orthop Surg 2008;16:506.
[PubMed: 18768708]
Rios CG, Leger RR, Cote MP, Yang C, Arciero RA: Posterolateral corner reconstruction of the knee: evaluation of a technique with clinical outcomes and stress radiography.
Am J Sports Med 2010;38:1564.
[PubMed: 20445013]
+++
Anterior Cruciate Ligament Injuries
+++
Essentials of Diagnosis
++
- Mechanism is either noncontact deceleration/rotation injury or contact injury with valgus force to an extended knee.
- Patients often hear a “pop.” They note feelings of instability and the knee giving out with twisting activities.
- Substantial knee effusion is present within first 12 hours after injury.
- There is a high incidence of associated injuries, including meniscus tears.
- Lachman is most sensitive test for diagnosis; pivot shift or Losee test helps evaluate rotational instability.
- Segond sign (avulsion of the anterolateral capsule of the tibia) may be seen on plain radiographs.
- MRI is helpful to confirm diagnosis and verify any additional concomitant injuries.
++
The mechanism of injury should be elicited in any knee injury evaluation. This can guide the examination to additional structures that may also be injured. ACL injury can occur in a variety of ways; however, a few mechanisms predominate. The most common noncontact ACL injury mechanism involves a deceleration and rotational injury during running, cutting, or jumping activities. The most common contact injury involves either hyperextension and/or valgus forces to the knee by a direct blow.
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ACL injury is often associated with a “pop” heard by the patient at the time of injury. This piece of history is not ACL specific, however. Upon return to competition, the patient will often notice instability of the knee or describe the knee “giving out” with twisting activities. Substantial knee swelling secondary to a hemarthrosis typically occurs within the first 4–12 hours following the injury.
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Signs (Physical Examination)
++
With the above history obtained and a proper physical examination, an ACL tear should be able to be diagnosed without any additional tests. A complete examination of the knee should be performed to evaluate for any other associated injuries. The uninjured knee is examined first to familiarize the patient with the knee examination.
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The Lachman test is the most useful test for anterior laxity of the knee. The Lachman test is performed with the knee in 20–30 degrees of flexion as an anterior force is applied to the tibia while the other hand stabilizes the distal femur. The degree of anterior translation and the presence and character of an end point are assessed. The laxity is graded based on comparison to the uninjured contralateral knee. Grade 1 laxity is 1–4 mm of increased translation. Grade 2 laxity is 5–9 mm of increased translation. Grade 3 laxity is more than 10 mm of translation as compared to the injured contralateral knee.
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The anterior drawer test is another test to evaluate anterior tibial translation. This is performed with the knee in 90 degrees of flexion as an anterior force is applied to the tibia. This test is less sensitive than the Lachman test.
++
In the acute setting of an ACL tear, there is often a window where an accurate examination can occur before extensive knee swelling and guarding inhibit examination. Aspiration of a hemarthrosis can help to decrease pain and improve the quality of the examination in the acute setting as well.
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The pivot shift test (Losee test) is performed to test the rotational instability associated with an ACL tear. The test is based on the lateral tibial plateau subluxing anteriorly with extension and reduction of the lateral compartment with flexion. The most effective method of achieving this result is by flexing the knee with an axial load from full extension with valgus stress at the knee and internal rotation of the tibia. The reduction of the subluxation should occur at approximately 30 degrees of flexion. MCL injury and some meniscal tears may produce a false-negative test.
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The pivot shift test is considered the most functional test to evaluate knee stability after ACL injury. An examination under anesthesia is also often useful in obtaining a more accurate pivot shift test. This can be useful in a patient with an unclear history of instability and an equivocal examination in the office.
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Plain radiographs of the knee should be obtained to rule out fractures about the knee. The Segond fracture, as discussed earlier, is an avulsion of the anterolateral capsule of the tibia. Before skeletal maturity, an avulsion of the tibial insertion of the ACL can also be seen radiographically. Following radiographs, an MRI is the most useful examination for an evaluation of associated injuries. Although generally not needed for diagnosis of an ACL tear, MRI can diagnose an ACL tear with 95% or better accuracy. Bone bruises of the lateral femoral condyle and lateral tibial plateau are noted in up to 80% of ACL injuries.
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Instrumented laxity evaluations can augment the physical examination and provide an objective baseline for future comparison. The most commonly used arthrometer, the KT-1000 (MEDmetric, San Diego, CA), uses a series of standard forces to measure anterior translation of the tibia with the knee in 20–30 degrees of flexion similar to the Lachman test.
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Rehabilitation following an isolated ACL injury should include an effort to regain knee motion and strengthen the muscles about the knee. Returning to activities that produce episodes of instability is discouraged. Once motion and strength have been restored, a gradual return to activities can be attempted to determine the functional level that can be attained without instability.
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Nonoperative management with rehabilitation after an ACL injury generally yields poor results in patients who return to competitive activities. Significant episodes of instability resulting in pain, swelling, and disability occur in about 80% of individuals who participate in sporting activities such as tennis, football, and soccer. These episodes of instability are thought to place the menisci and articular cartilage of the knee at risk for further injury (Figure 3–15).
++
++
The decision to surgically reconstruct an ACL tear is individualized and based on the patient's desire to return to competition, age, accompanying degenerative changes, and objective and subjective knee instability. For example, a young, active patient with continued desire to compete in cutting and jumping sports with both objective and subjective knee instability may be best treated with surgical reconstruction. On the other hand, an older patient with some degenerative arthritis of the knee and minimal desire for continued competitive athletics and no subjective instability would be much more suited to nonsurgical care.
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Early in the history of ACL surgery, primary repairs of the ligament were found to do poorly. This gave way to ligament reconstruction using a variety of graft materials. Everything from synthetics to autograft and allograft tissues has been used for reconstruction of the ACL. Over time, autograft bone-patellar tendon-bone, semitendinosus/gracilis hamstring autograft, and allograft bone-patellar tendon-bone constructs have proven to be the most commonly used grafts and have been successful for ACL reconstructions.
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The goal of ACL reconstruction is to reproduce the strength, function, and location of the intact ACL. Recently, there have been some articles challenging the results seen after single-bundle reconstruction. They point to instability in up to 30% of patients and only a 60–70% return to sport. Therefore, in an effort to replicate the normal anatomy and try to improve outcomes after ACL surgery, the double-bundle reconstruction has been advocated. This technique attempts to take advantage of the anatomy of the native ACL, which is composed of two bundles: anteromedial (AM) and posterolateral. The AM bundle is thought to provide stability to anteroposterior movement, and the posterolateral bundle provides rotational control. Advocates of the double-bundle reconstruction point to its ability to resist rotatory loads and mimic normal knee kinematics more closely. Biomechanical and some level I studies have demonstrated a benefit in objective rotational stability, but a clear clinical improvement has not been proven versus traditional single-bundle reconstruction. Double-bundle versus single-bundle reconstruction of the ACL remains a controversial and highly debated topic. Regardless of whether single-bundle or double-bundle reconstruction is used, the focus should be on attempting to restore the normal anatomy of the ACL with the position and placement of the tunnels.
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Once a graft of adequate strength is selected, the location of placement of the graft is of utmost importance. The graft is generally passed through a bone tunnel in the tibia and a bone tunnel through the femur. The intraarticular placement of the tibial tunnel is generally in the center of the native ACL stump just in front of the PCL origin and just medial to the center of the notch in the coronal plane for a single-bundle reconstruction (Figures 3–16 and 3–17).
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Once the graft is in place, the proper tension and fixation of the graft must occur to achieve a successful ACL reconstruction. Establishing proper tension in the graft is important. A lax ACL graft may not restore stability to the knee, and an overtightened graft may cause failure of the graft or limit knee range of motion. Fixation of the graft is achieved through a variety of measures. The most common method involves placing an interference screw up the bone tunnel that captures the graft in the tunnel. The graft can also be fixed via sutures tied over various devices located on the outer cortex of the tunnels.
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There are a couple differences to point out with the double-bundle reconstruction. First, an accessory AM portal is required in addition to the AM and anterolateral portals normally required for a knee arthroscopy. This portal becomes crucial for drilling accurately the femoral-sided tunnels, especially the AM femoral tunnel. Furthermore, special attention is taken to examine the tear pattern, which helps in locating the native locations of the AM and posterolateral bundles. Measuring the width/length of the insertions is also important because an ACL insertion less than 12 mm is extremely difficult technically to perform. Care must also be taken to ensure that there is at least a 2-mm bridge of bone between the two tunnels or the risk of convergence of the tunnels becomes very high. The recommended grafts by the authors at Pittsburgh are two tibialis anterior or posterior allograft tendons. Fixation on the femoral side is done with EndoButtons (Smith and Nephew endoscopy) and on the tibial side with interference screws. The grafts are tensioned at 0–15 degrees for the posterolateral bundle and 45–60 degrees for the AM bundle.
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Although ACL reconstruction often results in a successful outcome, there are several complications that can occur. One of the most common complications is a loss of knee motion. This is minimized by obtaining and maintaining full knee extension immediately following surgery. Knee flexion exercises are begun as soon as possible postoperatively, with a goal of 90 degrees by 1 week after surgery. Additionally, patellar mobilization is performed in an attempt to minimize patellofemoral scarring. Another common complication of ACL reconstruction is anterior knee pain. The exact etiology of this pain is unclear. However, it is thought that patellar tendon autograft harvest may increase the incidence of patellofemoral pain. Less common complications (<1%) include patellar fracture, patellar tendon rupture, and quadriceps tendon rupture depending on the graft harvest site.
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Results/Return to Play
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The goal of any rehabilitation protocol for an ACL reconstruction is to return the patient to the full desired level of activity in as short amount of time as possible while avoiding any complications or setbacks. Through improved surgical techniques and accelerated rehabilitation protocols, most studies have shown a 90% or better return to play and patient satisfaction. Patients generally are able to return between 4 and 6 months postoperatively, with some professional athletes returning successfully to competition in 3 months. Specific criteria for return to sports vary from institution to institution, with a combination of functional testing, subjective reporting, and clinical examination contributing to the decision. In general, the criteria for return to sports include full range of motion, KT1000 testing within 2–3 mm of the uninjured knee, ≥85% quadriceps strength and full hamstring strength, and functional testing within 85% of the contralateral leg.
Herrington L, Wrapson C, Matthews M, et al: Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery.
Knee 2005;12:41.
[PubMed: 15664877]
Järvelä T, Moisala AS, Sihvonen R, et al: Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized clinical study with 2 year results.
Am J Sports Med 2008;36:290.
[PubMed: 17940145]
Laxdal G, Kartus J, Hansson L, et al: A prospective randomized comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction.
Arthroscopy 2005;21:34.
[PubMed: 15650664]
Prodromos CC, Fu FH, Howell SM, et al: Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation and harvest.
J Am Acad Orthop Surg 2008;16:376.
[PubMed: 18611995]
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Posterior Cruciate Ligament Injuries
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Essentials of Diagnosis
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- Most common mechanisms of injury are a direct blow to the anterior tibia with the knee flexed or a fall into the ground with the foot plantar flexed.
- Patients complain of knee pain, swelling, and stiffness.
- Physical examination may show positive posterior drawer, Godfrey, and reverse pivot shift tests.
- Must perform thorough knee exam because concomitant injuries are common with PCL injury (posterolateral corner, meniscus).
- Imaging studies should include plain radiographs as well as confirmatory MRI. Radiographs are helpful in chronic setting of PCL to assess patellofemoral and medial compartment arthritis.
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When evaluating a patient for a PCL injury, it is important to obtain the mechanism of injury, the severity of the injury, and any potential associated injuries. In contrast to an ACL tear, it is rare for patients with PCL injuries to report hearing a “pop” or report any feelings of subjective instability. More commonly, patients will complain of knee pain, swelling, and stiffness.
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The presentation of a patient with a subacute or chronically injured PCL can range from asymptomatic to significant instability and pain. Patients with significant varus alignment or injury to the lateral structures of the knee will often complain of feelings of instability and giving way. There are a few characteristic mechanisms of PCL injury that differ significantly from the mechanism of ACL injuries. One of the most common mechanisms of PCL injury is the “dashboard” injury during which the anterior tibia sustains a posteriorly directed force from the dashboard with the knee in 90 degrees of flexion. Sports injuries to the PCL result from an outside force or blow, in contrast to the typical deceleration twisting mechanism of an ACL injury. The most common methods of a sports PCL injury include a direct blow to the anterior tibia or via a fall onto the flexed knee with the foot in plantar flexion. The most common mechanism for isolated PCL injury in the athlete is a partial tear associated with hyperflexion of the knee. Additionally, significant multiligamentous knee injuries with PCL tears can be seen after a varus or valgus stress is applied to the hyperextended knee.
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Signs (Physical Examination)
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As with other ligamentous injuries, a thorough knee examination is necessary. Specific cues to injury to the PCL on initial inspection include abrasions or ecchymosis around the proximal anterior tibia and ecchymosis in the popliteal fossa. Assessment for meniscal damage and associated ligamentous injury should be performed. Evaluation of ACL laxity in the presence of an acute PCL injury is challenging due to the lack of a stable reference point to perform a Lachman or anterior drawer test.
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Examination of the PCL in the acutely injured knee can be challenging. Despite increased awareness of the injury, many PCL injuries go undiagnosed in the acute setting. The most accurate clinical test of PCL integrity is the posterior drawer test. The knee is flexed to 90 degrees with the patient supine and a posteriorly directed force is applied to the anterior tibia. The amount of posterior translation and the presence and character of the end point are noted. The extent of translation is assessed by noting the change in the distance of the step-off between the AM tibial plateau and the medial femoral condyle. The tibial plateau is approximately 1 cm anterior to the medial femoral condyle on average. However, the contralateral knee must be examined to establish a baseline.
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Another test for examination of the PCL is the posterior sag or Godfrey test. This test involves flexing the knee and hip and noting the posterior pull of gravity creating posterior “sag” of the tibia on the femur. An adjunct to this test involves watching for a reduction of this subluxation with active quadriceps contraction.
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The reverse pivot shift is the analog to the pivot shift in the evaluation of an ACL injury. This is performed by placing a valgus stress on the knee with the foot externally rotated. The knee is then extended from 90 degrees of flexion, and a palpable reduction of the posterolateral tibial plateau is noted between 20 and 30 degrees of flexion.
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It is extremely important to evaluate the posterolateral structures of the knee in the setting of a suspected PCL injury. Injury to the posterolateral structures has been reported to occur in up to 60% of PCL injuries.
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Given the magnitude of the forces required to injure the PCL, plain radiographs of the knee are essential to evaluate for bony injuries, dislocation, or evidence of other associated injuries. Subtle posterior subluxation on the lateral radiograph may also indicate PCL injury. Stress posterior drawer radiographs and contralateral comparisons may also increase the sensitivity for detecting PCL injuries with plain radiographs. In the chronic setting of PCL injury, radiographs are useful to assess for patellofemoral and medial compartment degenerative changes that can occur over time.
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Although plain films are necessary and useful in the evaluations of these injuries, MRI has become the diagnostic study of choice for the knee with a presumed PCL injury. MRI has been reported to be 96–100% sensitive at diagnosing PCL tears. Equally or more importantly, MRI is extremely valuable in its ability to detect associated injuries. This is particularly important in diagnosing posterolateral corner injuries because these can often be missed on the initial clinical examination. In multiligamentous knee injuries, MRI can also be of use in assessing the ACL as clinical examination of the ACL is challenging in the setting of a complete PCL tear.
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In the setting of a chronic isolated PCL tear, pain in the medial and patellofemoral compartments is generally evaluated with radiographs. If these are normal, some surgeons will proceed with a bone scan to evaluate for increased uptake in these areas. Areas under increased stress demonstrate increased uptake on the bone scan before signs of advanced arthritis occur on radiographs. This subset of patients may benefit from a PCL reconstruction to decrease the stress and delay osteoarthritis.
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There is significant controversy in the treatment of isolated PCL injuries. There are multiple factors that must be evaluated in the decision to treat a complete PCL rupture. The patient's age, activity level, expectations, and associated injuries must be taken into account. The literature on operative versus nonsurgical treatment of these injuries can be difficult to interpret, and there are no long-term follow-up studies of randomized patient groups.
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Rehabilitation of the PCL injured knee is often largely dependent on the associated injuries sustained by the knee. This is particularly true with the commonly associated posterolateral corner injury. Therefore, we will focus on the rehabilitation of the isolated PCL injured knee. Regaining motion and strength are the two key objectives of a rehabilitation program. Obtaining full quadriceps strength is essential for achieving the optimal result with nonsurgical treatment. The initial treatment is aimed at keeping the tibia reduced under the femur and minimizing tension on the injured PCL. With partial injuries (grade I and II), the prognosis is quite good, and early motion with weight bearing is the usual course of therapy. In a complete PCL tear, most will keep the knee immobilized in extension to protect the posterolateral structures. Early strengthening exercises focus on quadriceps strength with quadriceps sets, straight leg raises, and partial weight bearing in extension.
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Overall, most patients benefit from nonsurgical treatment of a PCL tear. Despite objective findings of instability that are often noted on examination, most patients subjectively are satisfied with the function of the knee. Bracing is generally ineffective in controlling PCL laxity clinically.
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The main subjective complaint with chronic PCL insufficiency, however, is pain rather than instability. A PCL-deficient knee with posterior tibial subluxation places significantly increased stresses on the patellofemoral and medial compartments of the knee. In one series where patients with PCL injuries were followed with serial radiographs, 60% of patients displayed some degenerative changes of the medial compartment.
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Surgical management of PCL injuries are broken down into avulsion fractures, isolated acute PCL injuries, multiligamentous injuries, and chronic PCL insufficiency. Avulsion fractures of the PCL are rare fractures. If nondisplaced, these injuries are treated nonsurgically. If significantly displaced, these fractures are generally treated with open reduction and internal fixation.
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Isolated PCL injuries are generally still treated with nonsurgical care by the majority of surgeons at this time. However, it has been shown that nonoperative care of these injuries is not without consequences. Although subjective results in these patients are good in the short term, many continue to have objective instability and display degenerative arthritic changes over time. A follow-up of PCL-deficient knees at an average of 15 years after injury found that 89% of patients had persistent pain and half had chronic effusions. All patients in this group showed degenerative changes when followed for 25 years. Therefore, given the risks of continued instability and the potential of an increased chance of arthritic changes, surgical reconstruction of the PCL is a reasonable choice.
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Initially, surgical care of complete PCL tears consisted of a primary repair of midsubstance tears. The objective stability of these repairs was generally disappointing. Current reconstruction methods generally involve routing either autograft or allograft tendons through bone tunnels to reconstruct the PCL in an anatomic fashion. Although there are several different methods of reconstructing the PCL, the two main categories of PCL reconstruction consist of single- and double-bundle repairs. Classically, reconstructions of the PCL anatomically replicated the anterolateral bundle of the native PCL with a single-bundle reconstruction. As problems were noted with recurrence of posterior laxity in the postoperative period, a double-bundle technique was derived to reconstruct both the anterolateral and posteromedial bundles of the native PCL. The advantages of the double-bundle technique are thus far theoretical, and there is no long-term clinical follow-up demonstrating the superiority of a double-bundle reconstruction at this time.
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The severe instability noted with PCL injuries associated with multiligamentous knee injuries makes the argument for ligament reconstruction more compelling in this patient population. Many of the studies involving PCL reconstruction in these complex knee injuries have involved primary repair attempts. Although subjective results were generally good, residual excessive, objective laxity was very common following repairs. More recently, ligament reconstructions with allograft and autograft have become the dominant method of PCL reconstruction in this challenging patient population.
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The most common complication following PCL reconstruction is the return of objective posterior laxity on physical examination. This does not present as subjective laxity, however, and patient satisfaction remains high despite objective laxity. Acute PCL reconstructions in the setting of a multiligamentous knee repair/reconstruction can result in arthrofibrosis with extensive postoperative scarring.
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Results/Return to Play
++
Even with nonsurgical management of a PCL injury, the prognosis for a functional recovery and return to competition is very good. A strong quadriceps muscle and extensor mechanism can significantly compensate for PCL laxity. Athletes should spend a minimum of 3 months in rehabilitation before attempting a return to competition. However, a subset of patients experience significant instability with a grade III PCL injury that does not allow a return to competition. This subset of patients may benefit from PCL reconstruction.
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On the other hand, the prognosis for a PCL tear associated with a multiligamentous knee injury is guarded with respect to return to play. Although prompt recognition of a multiligamentous injury and appropriately timed treatment, reconstruction, and rehabilitation are essential for optimal recovery, these injuries are such that a significant percentage of patients will not be able to return to full competition.
Jung TM, Lubowicki A, Wienand A, Wagner M, Weiler A: Knee stability after posterior cruciate ligament reconstruction in female versus male patients: a prospective matched-group analysis.
Arthroscopy 2011;27:399.
[PubMed: 21168303]
Li G, Papannagari R, Li M, et al: Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion.
Am J Sports Med 2008;36:474.
[PubMed: 18057390]
Lien OA, Aas EJ, Johansen S, Ludvigsen
TC, Figved W, Engebretsen L: Clinical outcome after reconstruction for isolated posterior cruciate ligament injury.
Knee Surg Sports Traumatol Arthrosc 2010;18:1568.
[PubMed: 20571763]
McAllister DR, Petrigliano FA: Diagnosis and treatment of posterior cruciate ligament injuries.
Curr Sports Med Rep 2007;6:293.
[PubMed: 17883964]
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CPT Codes for Ligament Injuries to the Knee
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- 27405 Repair, primary, torn ligament and/or capsule, knee; collateral
- 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate
- 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments
- 27427 Ligamentous reconstruction (augmentation), knee; extraarticular
- 27428 Ligamentous reconstruction (augmentation), knee; intraarticular (open)
- 27429 Ligamentous reconstruction (augmentation), knee; intraarticular (open) and extraarticular
- 27552 Closed treatment of knee dislocation; requiring anesthesia
- 27556 Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstruction
- 27557 Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair
- 27558 Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair, with augmentation/reconstruction
- 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
- 29850 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)
- 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
- 29876 Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral)
- 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)
- 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction
- 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction
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Essentials of Diagnosis
++
- Almost always a lateral dislocation.
- Pain, swelling, and tenderness over medial border of the patella and apprehension with knee flexed and patella pushed laterally.
- Check hypermobility of the contralateral knee for comparison.
- Look for osteochondral fragment on radiographs.
++
Dislocation of the patella is a potential cause of acute hemarthrosis and must be considered when evaluating a patient with an acute knee injury. The injury occurs when valgus force and external rotation of the tibia are applied to a flexed leg. It is most common in females in the second decade of life.
++
The patella almost always dislocates laterally. The patient may notice the patella sitting laterally or might say that the rest of the knee has shifted medially. It is unusual to see actual dislocation of the patella except at the time of injury. Reduction occurs when the knee is extended.
++
Examination will demonstrate tenderness over the medial retinaculum and adductor tubercle, which is the origin of the medial patellofemoral ligament. The patient will also have pain and apprehension when the patella is pushed laterally with the knee slightly bent. Radiographs, including an axial patellar view, should be obtained to determine whether there are osteochondral fractures. Often, a small fleck of bone is avulsed by the capsule on the medial aspect of the patella. This is not intraarticular and does not require removal. A displaced osteochondral fracture will require excision or internal fixation. Examination of the uninjured knee is recommended to determine whether there are predisposing factors for dislocation, such as patella alta, genu recurvatum, increased Q angle, and patellar hypermobility. Patella alta, or high-riding patella, is identified by measuring the length of the patellar tendon and dividing by the length of the patella. The upper limit of normal is 1.2. The Q angle is formed by a line through the patellar tendon intersecting a line from the anterior superior iliac spine in the center of the patella. A normal Q angle is about 10 degrees, with a range of about plus or minus 5 degrees. Patients with generalized hypermobility have increased extension of the knee, or genu recurvatum, which in effect gives them patella alta. They also often have hypermobility of all the capsular ligamentous structures, including the static stabilizers of the kneecap, giving them significant patellar hypermobility.
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Treatment and Prognosis
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A wide variety of treatment options have been recommended for patellar dislocations, including immediate mobilization and strengthening exercises, immobilization in a cylinder cast for 6 weeks followed by rehabilitation, arthroscopy with or without retinacular repair, surgical repair of the torn retinaculum, or immediate patellar realignment.
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Treatment is based on which predisposing factors are present. Little is lost by functional treatment, similar to the treatment of isolated MCL sprains, which is often successful. If dislocation recurs, realignment may be performed. A long-term study showed that patients treated surgically for patellar malalignment problems had a higher incidence of osteoarthritis than those treated nonoperatively.
Buchner M, Baudendistel B, Sabo D, et al: Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment.
Clin J Sport Med 2005;15:62.
[PubMed: 15782048]
Gerbino PG, Zurakowski D, Soto R, et al: Long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum 5 year follow-up
. J Pediatr Orthop 2008;28:118.
[PubMed: 18157056]
Smith TO, Davies L, Chester R, Clark A, Donell ST: Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review. Physiotherapy 2010;96:269. PMID: 21056161]
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CPT Codes for Patellar Dislocations
++
- 27340 Excision, prepatellar bursa
- 27420 Reconstruction of dislocating patella (eg, Hauser-type procedure)
- 27422 Reconstruction of dislocating patella, with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite-type procedure)
- 27524 Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft-tissue repair
- 27562 Closed treatment of patellar dislocation; requiring anesthesia
- 27566 Open treatment of patellar dislocation, with or without partial or total patellectomy
- 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
- 29435 Application of patellar tendon bearing cast
- 29873 Arthroscopy, knee, surgical; with lateral release
- 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
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Pain in the knee region is a very common complaint of athletes. If there is no history of an acute injury, then overuse is commonly the cause. The patient is often able to point to the area of pain. The history of activity must be obtained as well as overall evaluation of the extremities.
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Patellofemoral Disorders
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Essentials of Diagnosis
++
- Pain with activity involving stairs or hills.
- Commonly involves young females.
- Check Q angle, femoral anteversion, patellar mobility, and quadriceps strength and tone.
- On radiographs, look for valgus alignment of knee, OCLs, and patella alta.
++
This is a common complaint and is frequently bilateral. It is most common in females during the second decade of life. The patellofemoral joint is often the source of pain. Entities such as chondromalacia patella, patellofemoral arthralgia, and lateral patellofemoral compression syndrome are diagnostic considerations.
++
Patellar pain is often felt when going up or down hills or stairs, and there may be complaints of instability during walking, running, or other sports activities. These activities may create a joint reaction force of several times the body weight on the patella with each step. Swelling is seldom a complaint. If the pain is in one knee only, the patient may alter the way of climbing and descending stairs so that the affected leg is kept straight and each step leads with the same foot. This strategy significantly decreases the joint reaction force on the patellofemoral joint.
++
Many of these problems arise because the patellofemoral joint is semiconstrained, especially in the range of 0–20 degrees of flexion, and the constraint increases as flexion increases. The degree of constraint is also dependent on a number of other factors, including the angle of the sulcus of the femur, the presence or absence of patella alta, and the generalized ligamentous laxity of the patient. In addition, femoral anteversion and increased Q angle (Figure 3–19) may lead to increased instability of the patellofemoral joint. This lack of constraint may predispose the patella to frank dislocation, although subluxation is a much more common finding. The degree of congruity is anatomically variable and may lead to high-contact stresses caused by anatomic configuration and static and dynamic constraints on the patella. Increased pressure may cause pain and patellofemoral osteoarthritis.
++
++
On physical examination of the patient with patellofemoral subluxation, minimal findings in relation to complaints may be present. Occasionally, crepitance, a crackling or clicking sound, is found with flexion and extension. Quadriceps strength, tone, and bulk are usually reduced. Pain may be elicited at a particular angle of flexion by putting the knee through its range of motion with resistance. Subluxation may often be diagnosed with the apprehension sign, a rapid contraction of the quadriceps when the patella is passively moved laterally.
++
Roentgenographic examination will frequently show a valgus angulation of the knee on anteroposterior views. Occasionally, patella alta may be identified on the lateral view, and tangential views of the patella at various knee flexion angles will reveal a lack of contact of the medial facet of the patella with the medial facet of the trochlear groove of the femur. Lateral subluxation of the patellofemoral joint may also be observed.
++
This syndrome with a normal roentgenographic examination is frequently called chondromalacia patellae, or with subluxation identified on radiograph, it is referred to as patellofemoral subluxation. A more accurate term would be patellofemoral arthralgia, because patellofemoral subluxation was probably present prior to the onset of pain and because chondromalacia patellae (softening of the patellar cartilage) is an arthroscopic or pathologic diagnosis. Patellofemoral arthralgia is a clinical diagnosis.
+++
Chondromalacia Patellae
++
Initially, treatment is conservative, with the intent of improving quadriceps strength and stamina to stabilize the patellofemoral joint. Weight loss is prescribed to decrease the stress on the patellofemoral joint; reduction in loading the knee in the flexed position also accomplishes pressure reduction. Knee orthotics may be beneficial. When subluxation and fear of dislocation are major concerns, an orthotic that limits extension of the knee may be beneficial because the patella becomes inherently more stable with knee flexion. Nonsteroidal anti-inflammatory medication may be beneficial.
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Patellofemoral Arthralgia
++
Only when conservative treatment has been exhausted is surgical treatment considered. Alteration in the alignment of the patellofemoral joint may be beneficial in patellofemoral arthralgia. Lateral retinacular release followed by a period of conservative treatment will be beneficial in some cases. Distal realignment may be necessary to achieve appropriate alignment and reduction in pain in those cases with an abnormality such as valgus knee or increased femoral anteversion.
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Patellofemoral Compression Syndrome
++
With lateral patellofemoral compression syndrome, there is tenderness along the lateral facet of the patella or along the femoral condyle. Without cartilage damage, an effusion is rarely present. Treatment includes decreasing the activity level, including avoiding hills or step aerobics. Ice massage, quadriceps and hamstring stretching, and short-arc quadriceps exercises against resistance are recommended to strengthen the vastus medialis obliquus muscle without aggravating the pain. Patellar supports or neoprene sleeves may also be helpful. Most patients will respond to this regimen and gradually resume their activities. The role of releasing a contracted lateral patellofemoral retinaculum is controversial.
++
Patellar tendinitis, or jumper's knee, is seen in basketball and volleyball players. Tenderness along the tendon, usually at the inferior pole of the patella, is noted. Treatment with ice and avoiding jumping usually suffice. In refractory cases, debridement of mucinous degenerative material from the tendon may be successful.
++
The prognosis for jumper's knee is quite good. The condition is often persistent but self-limiting. The patient can always alleviate the symptoms by avoiding the activities that cause the problem.
Collado H, Fredericson M: Patellofemoral pain syndrome.
Clin Sports Med 2010;29:379.
[PubMed: 20610028]
+++
Iliotibial Band Friction Syndrome
+++
Essentials of Diagnosis
++
- Lateral knee pain.
- Commonly affects runners and cyclists.
- Tenderness over lateral epicondyle and positive Ober test.
++
Lateral knee pain that is not located on the joint line may result from iliotibial band friction syndrome. This is a form of bursitis caused by rubbing of the iliotibial band against the lateral epicondyle. Tenderness over the lateral epicondyle at about 30 degrees of flexion when the knee is being extended is indicative of this diagnosis. The Ober test, with abduction and then adduction of the leg, can also demonstrate the tightness of the iliotibial band when the patient is in a lateral decubitus position and the hip is hyperextended. Runners and cyclists are commonly afflicted. Crossover gait or running on banked terrain is thought to be a causative factor.
++
Treatment involves decreasing the athlete's activities, ice massage, stretching of the iliotibial tract, and use of a lateral wedge orthotic in patients with heel varus. Running on flat terrain and changing the gait pattern may be helpful. In cyclists, lowering the seat height so the full extension of the knee is not reached and adjusting the pedals so that the toes are not internally rotated should help. Steroid injections are infrequently needed, and release of the inflamed portion of the iliotibial band is seldom necessary. As for other overuse syndromes of the knee, the prognosis is good.
Hariri S, Savidge ET, Reinold MM, Zachazewski J, Gill TJ: Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes.
Am J Sports Med 2009;37:1417.
[PubMed: 19286912]
Lavine R: Iliotibial band friction syndrome.
Curr Rev Musculoskelet Med 2010;3:18.
[PubMed: 21063495]
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Other CPT Codes for the Knee
++
- 27305 Fasciotomy iliotibial band
- 27310 Arthrotomy, knee, with exploration, drainage, or removal of foreign body
- 27412 Autologous chondrocyte implantation, knee
- 27552 Closed treatment of knee dislocation; requiring anesthesia
- 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
- 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
- 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage
- 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
- 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
- 29876 Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral)
- 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
- 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)