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KNEE JOINT

TYPES OF KNEE JOINT ISSUES

  • Ligament injuries
  • Meniscus
  • Patella – MPFL (Re.Patellar subusation)
  • Cartilage
  • Intra-articular Proximal Tibia fracture
  • Osteoarthritis

LIGAMENT INJURIES

Mechanism of Injury : Ligament usually damage in twisting or rotational injury during sports, running or vehicular accident.
Immediate after injury main complains of patients are pain swelling, tenderness, deformity and instability. After some time pain and swelling subsides and main complains are instability, difficulty in running, jumping climbing stairs, apprehension of fall down.

  • Examination : Your surgeon is able to diagnose particular ligament injury by doing certain clinical tests.
  • Investigations : Diagnosis of ligament injury is confirmed by MRI (Gold Standard). Sometimes X-ray or CT scan may require to rule out bony injury.

    Mechanism of Injury : Ligament usually damage in twisting or rotational injury during sports, running or vehicular accident.
    Immediate after injury main complains of patients are pain swelling, tenderness, deformity and instability. After some time pain and swelling subsides and main complains are instability, difficulty in running, jumping climbing stairs, apprehension of fall down.

    • Examination : Your surgeon is able to diagnose particular ligament injury by doing certain clinical tests.
    • Investigations : Diagnosis of ligament injury is confirmed by MRI (Gold Standard). Sometimes X-ray or CT scan may require to rule out bony injury.

  • Cruciate ligaments, ACL & PCL are intraarticular ligaments.
  • Both ligaments only operated arthroscopically after swelling subsides and pain free Range of motion achieved. It takes around 3 to 6 weeks. Surgery should be delayed till bony or extra-articular repair/injury heal completely.
  • Ligament reconstruction done using hamstrings (semiTendinosis, gracillus), patellar tendon(BPT), Quadriceps, peroneus longus tendon. Hamstring graft is most commonly used autocraft for ligament reconstruction because it is easy to harvest strong and very less donor sites morbidity. Other grafts normally used in revision or multiligament reconstructive surgery.

  • ACL (Anterior Cruciate Ligament) is a key stabilizer of knee joint. It is the most commonly injured ligament in the knee. Once the ACL is form, the knee usually becomes unstable.
  • Once ACL torn completely knee become unstable, it requires arthroscopic ACL reconstruction. It is highly successful surgery and move than 90% of patients are able to return to preinjury activity level.

  • Posterior cruciate ligament is second major ligament of the knee joint.
  • Surgical reconstruction of PCL is tricky operation as a part of the operation is done at the back of the knee an area where important nerves and blood vessels of the leg lie.

  • Medical & lateral collateral ligaments (MCL & LCL) are extra articular ligaments. When patient come early or immediate after injury open repair is preferred. If delayed presentation with complains of instability reconstruction should be done.

  • More than one ligament damage occurs in serious accidents. The knee becomes severely unstable. In this severe injuries, damage to the nerves and vessels of the leg may occur and may make this injury limb threatening. This injuries need surgical repair/reconstruction depending upon type of ligament injury.

MENISCUS

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Meniscus is a soft rubber – like c-shaped cushion. It helps in load sharing across the knee. There are two problems :

  • one it degenerates (become weak) with age and
  • two it tears due to injury.

Torn meniscus becomes a ‘misfit’ in the joint and gives rise to mechanical symptoms such as locking, catching, clicking etc. Over a period of time, these mechanical symptoms cause damage to soft covering (cartilage) over the bones. This is called osteoarthritis and is irreversible damage to the joint.

Till a few decades back it was considered a vestigial structure, and was removed. Recent trend is to save the meniscus. A small tear can heal itself. A bigger tear whenever possible is sutured and if suturing is not possible partial menissectory done. This surgery is done by key-hole technique(arthroscopy)/ and takes 15 – 20 minutes to do the job.

PATELLA

Recurrent Patellar subluxation/dislocation :

  • When medical patello femoral ligament (MPFL) is torn, patella subluxate or dislocate laterally.
  • In Acute cases, it requires repair while in chronic recurrent patellar sublaxation MPFL Subluxation and sometimes lateral release done.
  • In some cases patellar sublaxation occur due to upper tibial or femoral deformity. Insuch case detailed evalution needed before doing any procedure or surgery.
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CARTILAGE

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  • Arthroscopic debridement involves excision or osteophytes, loose body removal and cartilage shaving. It may involve lavage, partial meniscectomy or limited synovectomy.
  • Drilling or microfracture of the subchondral bone has been done to treat small localized area of articular cartilage loss.
  • Theory is that the resultant hematoma tranforms into reparative fibrocartilage with restoration of the joint surface contour and symptoms relief.

Technique :

  • An awl/drill is used to make multiple holes in the exposed subchrondral bone of the defect.
  • This leads to bleeding and adhesion of the hematoma to the subchondral bone which may enchance fibrocartilage formation.

  • Autologus Osteochondral transfer or Mosaicplasty performed for small focal, full thickness chondral or Osteochondral defects in weight bearing part of femoral condyles, less than 30mm in diameter and preferably in young patients.
  • It is performed by transfering one or more cylindrical osteochondral autografts from a low or non-weight bearing part of the knee towards the defective site.
  • Axial deformity or instability should be treated simultanously.
  • Excellent results after this procedure are found but the primary limiting factor is the availability of autologus donor tissue.

  • Autologus chondrocyte implementation (ACI) should be done in larger cartilage defect (>30mm). In this technique few healthy cartilage cells are harrested and cultural them in laboratory grown millious of cells are implanted into the area of cartilage damage by injecting them under periosteal flap.
  • The results are satisfying but the technique is difficult (harvesting and suturing of the flap irregular spatial distribution of the cells).

INTRA-ARTICULAR PROXIMAL TIBIA FRACTURE

Intra-articular tibial Spine avulsion fracture of ACL is operated by arthroscopy. Arthroscopy is helpful in reduction and fixation of intra-articular alignment. Arthroscopy is also helpful in removal and post traumatic stiffness.

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OSTEOARTHRITIS

When cartilage of knee joint is extensively damaged with involvement of all compartment of joint, arthroscopy is not the choice of treatment. In such cases if conservative treatment is failed total knee replacement surgery is only choice of treatment.

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