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Treatment of knee DX
• Initial management
- Vascular inj - Open DX - Irreducible DX - Compartment syn
Vascular Injury• Palpable pulses alone do not rule out a significant
vascular inj • Screening for all knee DX (documented &
suspected ) recommended
• ABI > 0.9 means 100% negative predictive value for major Vascular inj
• ABI < 0.9 means more screening (CT angiogram)
Treatment
• Operative • Conservative
-superiority of Operative to conservative TX (ROM, functional outcome, stability, return to sport & work ) 32 studies after 2000 peskun et al;
Conservative treatment
• Indications
- Comorbidity (head inj-soft tissue problem )
- Old patient (osteoporosis- DJD )
- Skeletally immature patients
Conservative treatment
• Reduction
• Immobilization 3-6 wk in full Ext ( cast, splint or Ext Fix ; if can not maintain reduction)
• Rehabilitation
Operative treatment • Early (1-3 wk ) ( repair & augmentation ) -Avulsion FX -Stener lesion -Flipped or displased meniscal tear preventing ROM
• Delayed ( more than 3 wk ) ( reconstruction )
Operative treatment
• Stress x-ray under fluoroscopic imaging
- side to side diference ; Lat > 2.7 mm = isolated FCL > 4 mm = FCL, PLC
; Med > 4 mm =isolated MCL > 10 mm = MCL; PMC
• Arthroscopy for all patient ( meniscal,chondral, loose body )
• Tourniquet is applied but rarely inflated
Operative treatment (KD classification)
• KD 2 ( ACL - PCL without Med & Lat )
- delayed OP ( 6-8 wk after inj )
Operative treatment (KD classification)
• KD 3 M (distal tear ) ( stener lesion )
- early op ( MCL repair- ACL & PCL recons )
MCL repair (prox on Tib by anchor in full Ext & dist on Tib by screw –washer in 30 deg Flex )
Operative treatment (KD classification)
• KD 3 M ( MCL mid substance )
- repair is not effective
-delayed ( 6-8 wk ) ACL-PCL –MCL recons
Operative treatment (KD classification)
• KD 3 M ( prox )
- hinge knee brace ( 6-8 wk ) then ;
If – Med stable ; ACL- PCL recons
If – Med lax ; ACL-PCL –MCL recons
Operative treatment (KD classification)
• KD 3 M ( very extensive )
- stage 1 ( Med repair & augmentation with allograft )
- stage 2 (delayed (6-8 wk ) ACL- PCL recons )
Operative treatment (KD classification)
• KD 3 L (avulsion of fibular head )
-early fixation of avulsion & ACL- PCL recons - if quality of tissue or repair is not good go to augmentation
Operative treatment (KD classification)
• KD3 L ( mid substance & prox )
- delayed ACL-PCL –Lat recons
Operative treatment (KD classification)
• KD 4 ( global instability )
- if Med or Lat are reparable - stage 1 ; early repair of Med & Lat - stage 2 ; delyed ACL-PCL recons
-if Med or Lat are not reparable - delayed all Lig recons
FX-DX • As a general rule
-stage 1 ; FX fixation and after bone healing - stage 2 ; delayed Lig recons