Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle

www.oasir.co.uk

Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne

FRACTURES AROUND THE KNEE – CLINICAL PATTERN RECOGNITION AND

APPROPRIATE ACTION PLANNING

Prof Deiary Kader

Plan Knee Osteonecrosis Fracture around the Knee Advances in ACL Surgery Advances in PFJ instability PCL & PLC

Prof Deiary Kader

Nuffield Hospital/NewcastleICRC 2015

QEH Gateshead 2005-2015

QEHGateshead Health

Prof Deiary Kader

Knee Osteonecrosis (ON)

Spontaneous ON (SONK)

Secondary ON

Post-arthroscopic ON

Prof Deiary Kader

Spontaneous Osteonecrosis of the Knee (SONK)

Osteonecrosis without an identified cause. Females Middle age or elderly. Epiphysis of medial FC Lateral FC, Tibial plateau Almost always unilateral. Associated with meniscal root tear May represent a subchondral insufficiency /

stress fracture

Prof Deiary Kader

Clinical Presentation:

Sudden onset of severe knee pain (usually non-specific).

Can be focused over the medial femoral condyle

Decreased range of motion with no mechanical block

Effusion present in the acute stages Pain worse on activity

Prof Deiary Kader

Treatment : Non-operative:

Activity modification

Rest and non or partial weight bearing

Analgesia including NSAIDs

Targeted physiotherapy focusing in range of motion and quadriceps strengthening 

Prof Deiary Kader

Treatment Operative

 Only after conservative Rx -success is variable.

Retrograde drilling a trial with an off-loader brace is

recommended pre-operatively High tibial osteotomy (if mal-

alignment present) Arthroplasty (in larger lesions and

bone collapse)

Prof Deiary Kader

Outcome of SONK

Small, isolated lesions often regress and heal

Medium-sized lesions may regress

Very large lesions, subchondral collapse will occur, regardless of treatment

Prof Deiary Kader

Insufficiency Fractures of the MFC

Predominance in elderly women Osteoporotic bone Varus knee Obesity Trivial trauma Mechanical pain Increased radionuclide uptake. Rest and analgesics consistently

ensured a better outcome within three to four weeks

Prof Deiary Kader

Secondary OsteonecrosisSubchonrdal AVN

Often involves both femoral condyles Multiple lesions epiphysis, metaphysis,

diaphysis ne. Typically younger than 45 years It is bilateral more than 80% Direct risk factors

Radiation Chemotherapy Corticosteroid Trauma. Sickle cell disease or other myeloproliferative

Prof Deiary Kader

Treatment of secondary ON

Diagnosis at early stages Eliminate the causative factor if possible Nonsurgical treatment lead to poor

outcome Drill the lesions, may halt the

progression Supplement the drilling technique with

Bone morphogenetic protein Growth factors MSC

Prof Deiary Kader

Prof Deiary Kader

General causes of osteonecrosis include:

• TRAUMA

• CAISSON DISEASE

• HAEMOGLOBINOPATHIES SICKLE CELL DISEASE

• RADIOTHERAPY

• CONNECTIVE TISSUE DISORDERS

• RENAL TRANSPLANTAION

• CORTICOSTEROID EXCESS

• PANCREATITIS

• GOUT

• GAUCHER DISEASE

• ALCOHOL

Prof Deiary Kader

Post-arthroscopic ON

Heat damage to the bone Trauma during surgery Lesions are typically only found in the

epiphysis. Patient age and sex is not a factor. Some of the associated risk factors include

meniscectomy, cartilage débridement, and ACL reconstruction.

Prof Deiary Kader

Hoffa Fracture

Prof Deiary Kader

Isolated femoral condylar fractures in the coronal plane

Direct anteroposterior force applied to a flexed knee in a high-energy accident

Hoffa described the injury in 1904 as generally involving the lateral femoral condyle

Prof Deiary Kader

Prof Deiary Kader

Sleeve Fracture Patella

Prof Deiary Kader

Sleeve fracture occurs between the cartilage "sleeve" and main part of the ossific nucleus Age 8-12

Prof Deiary Kader

Patella Tendon Rupture

Prof Deiary Kader

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Prof Deiary Kader

Prof Deiary Kader

POSTGRAD ORTH Deiary Kader

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Sigond Fracturepathognomonic of ACL Rupture

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Tibial Eminence Fracture

Meyers and McKeever classification (1959)

Type I: non displaced

Type II: partially displaced or hinged

Type III: completely displaced (Type III)

Type IIIA (Zifko) involves the ACL insertion

Type IIIB (Zifko) includes the entire intercondylar eminence.

Type IV (Zaricznyj 1977): comminution of the fracture fragment.

Treatment

• Casting in extension for type I

• Open reduction and internal fixation.

• Arthroscopic reduction and fixation

• Rarely ACL reconstruction is necessary

Prof Deiary Kader

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Prof Deiary Kader

TP

Prof Deiary Kader

Tibial Plateau Fractures

Prof Deiary Kader

Tibial Plateau Fractures

Prof Deiary Kader

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Prof Deiary Kader

Metastatic cancer

Prof Deiary Kader

Only bone cyst

Prof Deiary Kader