Transcript
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ACL ligament injuries, the anterior cruciate ligament.
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If you're an athlete, a fitness enthusiast, or anyone who's ever taken a misstep, a ligament injury to the knee can be disastrous.
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Today, we're diving deep into a topic that touches the lives of so many.
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These complex injuries can sideline the best of us, affecting mobility, stability and overall quality of life.
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From the anterior cruciate to the posterior cruciate, the medial collateral or the lateral collateral, each ligament plays a critical role in the function and support of the knee.
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Today we're joined by Australian Rules football surgeon, Dr.
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Will Duncan, as we discuss his thoughts about these complex injuries.
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Welcome to Aussie Med Ed.
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G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field.
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I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide and I'm broadcasting from Kaurna Land.
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I'd like to remind you that this podcast is available on all podcast players and is also available as a video version on YouTube.
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I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow.
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I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging.
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I'd like to remind you that all the information presented today is just one opinion, and that there are numerous ways of treating all medical conditions.
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Therefore, you should always seek advice from your health professionals in the area in which you live.
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Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from the health organisations such as Lifeline in Australia.
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And today we're joined by Dr.
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Will Duncan, a specialist orthopaedic surgeon whose work focuses on the injuries of the knee.
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He's involved in the treatment of elite athletes and professional sports teams, and he also looks after the management of degenerative arthritis, for patients who want us to keep moving.
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He has a particular expertise in anterior cruciate ligament injuries, particularly complex ones, as well as arthroscopic meniscal repair, joint resurfacing, and cartilage restoration.
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Dr.
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Will Duncan has an advanced fellowship in joint replacements, which he obtained from Exeter in the United Kingdom, and works in a sports knee injury clinic, and consults at Wakefield Orthopaedic Clinic and Clare Medical Centre.
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He's going to talk to us about cruciate ligaments in particular, but also about ligament injuries around the knee.
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And we're looking forward to hearing his expertise in that area.
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Welcome Will Duncan.
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Thank you very much for coming on Aussie Med Ed and to talk to us about this really important injury.
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Obviously, knee injuries themselves are the bane of all sports people.
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Can you tell me, first of all, who suffers a knee injury?
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What sort of people suffer a knee injury?
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I presume there's sports people and also a generalised population get injuries too?
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Perhaps you can outline the sort of people you see.
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The people that I see are predominantly sports people, they're younger patients generally that's where the highest increase in injuries is occurring over the last decade.
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It's in our young athletes that are performing, a lot more single sports.
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They're not doing a variety of sports that they used to do in the past.
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They tend to focus on one sport and get very involved in training for one particular activity.
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And that's the group where the ACL and other injuries to the knee has become more prevalent.
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But also I see a lot of older patients that want to keep active and keep doing perhaps some lesser twisting and turning sports but still get similar injuries as they get older.
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Okay, have the incidents increased over the years?
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People seem to think that they have with the high level sports, or is it about the same?
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In Australia they looked at it.
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It's gone up about 5 percent per year increase in incidents.
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In males and a lot more perhaps in the females.
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And female athletes and females participating in sports have become a lot more common, particularly in higher impact and more aggressive sports such as rugby and tennis.
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Football and soccer, rather than just the netball.
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So the incidence females has gone up quite a lot.
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And is there a difference between female and male in the gender difference and the actual incidence of cruciates?
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I mean are ladies more likely to get it because of the size of their Cruciates or their relaxin hormone that may be in their system?
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Yeah, and there's a lot of theories about it, but certainly Sport for sport, the female athletes will have about four to six times as many ACL injuries as men.
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That's just looking at the ACL side of it and that does translate a bit to other ligaments.
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And the theories behind that are like you say, a different sort of anatomy in a female patient with a narrower notch around the ACL so it gets impingement in the knee and Also, the leg is a bit more valgus, so they're a bit more Knock Knee-ed.
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So that can potentially lead to more stress through the ACL playing sports.
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They've got a wider pelvis, they've got slightly reduced muscle bulk around the hips and the quads, and that's thought to lead to less protection of the knee during sport.
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And then, yeah, of course, the hormones as well.
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We're recently looking at a study here, of time of ACL injury and ovulation cycle in female athletes.
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It is indicating that there may be more ACL injuries around the time of ovulation.
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That's interesting stats.
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Is that something you could actually adjust?
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I can't imagine you can actually have a day off.
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Yeah, well, I think they are already looking at high level athletes and oral contraceptive pill treatment without regulating their monthly cycle so they can miss ovulation and perhaps miss out on getting increased risk for ACL injury and not letting them train or reducing training and activity levels during ovulation.
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So they're starting to look at it but there's not hard evidence behind it yet, it's still in the research stage.
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But yeah, it's a worry that sport for sport, there's such a big increase in the female population.
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And we started off with cruciates of course, but that's probably the predominant one you'd see as a surgeon, but what is the most common injury?
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I would have thought that medial collateral ligaments are probably slightly higher than ACLs, or is ACL more common than MCLs?
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Yeah, no, I think I think you're right.
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The the most garden variety injury on the sports field to a knee is MCL or medial collateral.
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The ACLs are, they are increasing because of, a number of reasons such as media attention and general community awareness and MRI scanners being available more readily than they used to be.
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So, we're seeing a lot more ACL injuries, but , they're about one in 2000 in the population, the ACL, whereas the MC L's probably 10 times that.
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And the other ligaments around the knee, the lateral and PCL or posterior cruciate, about 10 times less than the ACL.
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But yeah, certainly the biggest ligament injury, the knee is the medial collateral.
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injury.
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Unfortunately, they do heal up really well with nature.
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They're embedded in a lot of soft tissue.
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They've got a good blood flow and if you support them, they'll heal really well with a brace.
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Whereas the ACL, it sits in the middle of the knee and it has synovial fluid all over it, so it can't form a blood clot or scar tissue very easily and all the nutrients get washed away every time it tries to heal.
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So most ACLs don't heal very well with conservative therapy and end up needing a reconstruction if the knee is unstable.
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And what about the combination injuries too?
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Obviously lateral and posterior cruciates go together as do the anterior cruciate with MCLs and what, and there's also associations with meniscal injuries too.
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Perhaps you can outline what you generally tend to see as well in your practice.
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Yeah, I mean what you like to see with an ACL is an isolated injury because they have a lot less collateral damage in the joint and a lot less damage to the meniscus and the chondral surface, so if it's an isolated ligament injury and you do a good operation and they have good rehab, they can usually have lifelong good function in their joint.
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But they're not always isolated if you're aware they've The most common injury with an ACL is a posterolateral meniscal tear and also lateral compartment damage because the lateral side of the knee gets compressed as the knee pivots out of joint.
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So, you do get lateral side of compression and MCL sprains with ACL injuries and that can lead to cartilage damage, chondral damage and meniscal damage which then progresses later in life to osteoarthritis.
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So yeah, they're usually combined with some form of, an ACL is usually combined with some form of medial collateral sprain and a lateral sided bone impaction or meniscal tear.
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And as you said before, the lateral ligament injury is often combined with PCL damage just from the mechanism of force.
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Yeah, I always seem to think of the posterolateral corner as being more of a high trauma, almost like a motor vehicle accident type of injury, while the other combination of ACL and MCL being more of a sports injury.
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Would that be right or is there a, do you see the other lateral posterolateral corners in sports injuries as well?
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You see them in sports as well, but a lot less common.
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ACLs and MCLs, particularly ACLs, are usually an isolated injury.
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or a non contact injury.
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It's usually from change of direction or landing on an unsupported knee that gives way and there's usually no other athletes involved in the injury, whereas the posterolateral corner of PCLs, it's a direct blow to the knee, usually from the inside of the joint.
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So, you see it in motor vehicle or motor bike accidents, skiing injuries, high velocity injuries, and not so much in running sports, but occasionally rugby and things where you get someone, diving and taking out the legs, they might come across the inside of the knee and take out the lateral or posterolateral corner.
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So a lot less common and more associated with high velocity trauma and being flung from a motor vehicle.
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So what about the isolated meniscal injury, which we haven't talked about?
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Do they occur commonly?
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I know I sustained one when I was young, but I don't know if they're as common as I thought.
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How often do an isolated meniscal injury occur in a sports person?
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I don't really know the answer to that.
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I think you do see them.
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But usually in the sports patients that are younger, they've got really rubbery Meniscal tissue, it's not brittle and stiff and it does accommodate a lot of twisting and turning and impact.
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So to tear it, you need to have a fairly big force which in turn does cause other damage like ligament damage.
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So yeah, I think you're probably right unless they've got some underlying meniscal degenerative problem or a discoid meniscus which they're born with which is a big floppy lateral meniscus.
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Unless they've got those problems, they don't usually get isolated meniscal tears.
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So for the general practitioner or medical student coming through working in a GP practice and they see a person who's had an injury, what part of their history would you really want to isolate then?
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What do you focus on?
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I think you've already emphasised the importance of running in non contact injury versus direct trauma.
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Are there any other things you might want to take into account when you're assessing them before you go into the examination?
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And then we'll talk about the examination after that.
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I think on the history side of things with knee injuries it's about the pain and early mobilisation or weight bearing afterwards if they're able to get back on their leg and walk.
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Usually they don't have a fracture and that's one of the sort of rules for further investigation is if they can weight bear it's a good sign.
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The other thing on history is whether the knee felt unstable or whether the knee suddenly swelled up, which means that they've got bleeding in the joint and bleeding in the joint can mean fracture, but usually means an ACL rupture.
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So early sudden swelling and not being able to weight bear or get back on the field are usually good signs that they need further close assessment and they've probably got a fairly major injury, whereas if they can still walk, they don't get much swelling and they go back on and play the rest of the game, then usually they've got a more minor injury that may not need such close attention.
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So what, when do you come to examine a knee, what are the key steps that you look at when you assess them?
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Obviously we like to look for your move principle in orthopaedics, but
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Yeah, we're pretty simple guys, I think that's the main gist of all orthopaedics.
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With examination you wanna look at their gait.
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So that's pretty easy.
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When they walk into your room, you've already done half your assessment looking at, the alignment of the leg and whether they can weight bear and whether it's antalgic or whether it's just a normal gait.
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So from that, you can get a few little tidbits of, if they've got a really bent leg, or they're not putting the weight through, or they've got a flexion deformity, you know something's wrong.
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And that's really the looking, as well as looking for swelling, around the joint, if it's got a large effusion.
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And, usually they're acute injuries, so you won't see wasting of the muscle at that stage, but you might later on.
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And then, obviously, feeling the joint for effusion, and tenderness, and warmth.
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And then feeling the ligaments for stability.
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There's a lot of different stability tests and some of them are fairly sensitive and specific and some aren't.
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So, if you look at, tests for ligaments and ACL in particular the pivot shift test, which is very difficult to do in a patient with an acute injury is very sensitive and very specific for ACL.
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The other tests, such as your anterior draw, can be a little bit confused with PCL and ACL laxity.
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And the Lachman, similar, can be a bit confused, but generally the PIVOT's the gold standard.
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And most knee orthopaedic surgeons can do those tests and get better at them, but they are quite a specific and difficult test to do in general practice.
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And that's obviously where you internally rotate the tibia on the femur.
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and go from extension to flexion I believe it's actually, it drops back and then actually reduces as you do the extension deflection.
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Yeah, so if you put the leg out straight and rotate it internally and put a bit of axial load on and a bit of algus, it subluxes the tibia off the lateral femoral condyle.
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And as you flex the knee up, it clunks back into position.
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And if they've got a pivot, they're, 98 percent likely to have an ACL, incompetent knee.
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Whereas if they've got a Lachmann or a anterior drawer, it's only sort of 60 percent likely to be an ACL.
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And when you're testing for a posterior cruciate, do you rely purely on a posterior sag when you assess?
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Yeah, pretty much.
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That's the simplest thing is put both knees up together at 90 degrees and see where the tibias are sitting.
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And if you've, Got one tibia sagging backwards, then that's a fair sign the PCL's gone.
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It doesn't tell you much about the other ligaments and postero-lateral corner, but it does tell you the PCL's loose.
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That's the easiest thing for PCL testing.
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There's a reverse pivot, which is nearly impossible.
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And there's an active quads test you can do and things, but probably just the sag test is the most reliable for PCL.
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And how important do you put on grading the actual laxity in the anterior and posterior cruciates?
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And what grading system do you tend to use?
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Like all, look, feel, move, we use 1, 2, 3 with most orthopaedics where 1 is minor, 2 is moderate and 3 is severe.
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And it can be measured in centimetres, like 1, 2, 3, or it can be measured in whether there's a little end point or no end point.
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It's really after a few years of experience.
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It's a good measurement if they've got a little bit of laxity grade 1 as opposed to gross grade 3 laxity where it's falling off the femur, particularly in older patients when you're working out whether they should or shouldn't have a reconstruction because As you get older, you don't need to pivot sport as much and twist and turn as much, perhaps as a younger patient, and you can put up with a Grade 1 laxity in most people.
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So that's when you're starting to grade to work out what sort of treatment you're going to offer.
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What about assessment of the collaterals then?
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Do you just do a stressing into valgus and varus, or do you do the bagpipe test where you place the leg under the arm?
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What do you find the easiest to do?
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I do place it under the arm, but I, and then support the leg.
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You've got to do it in a bit of flexion.
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If you do a, MCL or LCL test in full extension, all of the posterior capsule and PCL and ACL provide stability, whereas in a bit of flexion you take all that tension off and you get a true feeling.
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So, I find it easier to support the whole tibia Twist the knee from side to get a feeling of great laxity of the medial or lateral collateral.
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Right.
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Excellent.
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So, you've gone through, you've taken a history, you've heard the story of the person running and landing awkwardly from a jump, or changing directions, and you're concerned that the knee has swollen up acutely.
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And you've examined them and you feel there is some instability, perhaps on the medial and also on the cruciate.
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What's the investigation of choice?
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And how does it vary if they can't walk straight off?
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Would you do, in that latter scenario, would you do an X ray first?
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Or how would you progress?
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Yeah, I think X rays are a fairly important test for orthopaedic surgeons.
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We do like them.
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They're becoming less well less, you don't see as many of them in acute injuries because MRI is so available.
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They're the only really two tests that we see is X ray or MRI.
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I think the x ray is really good if they've got no weight bearing tenderness over the patella or the fibula.
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If they're over 50 and if they've got a larger effusion, they're probably the rules for getting an x ray.
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Other than that, it's nice to have an x ray to look at growth plates in younger patients and that sort of thing.
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But you don't have to have them unless they've got a major tender spot or they're older or they can't walk.
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So X rays are good and you can see some of the subtle findings for ACL in ligament injuries like avulsion, Segond fractures where the capsules pulled off or lateral impaction of the condyle.
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So you can see some of the, some bigger problems that are going on if they're there.
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For the listener, just outline exactly the location of the Segond fracture again.
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Like
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all things around knees and elbows and things, you've got the capsule which has some thickenings in it and some sort of small unnamed or sometimes named ligaments or thickenings in the capsule.
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And one of them's the lateral capsule of the knee that attaches just onto the tibia.
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It's not Gerdy's tubicle where the ITB attaches, but it's just above that.
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And there's some tight fibres which may represent the anterior lateral ligament, which is a ligament that runs from the femur down to the tibia, rather than the normal collateral goes to the fibula.
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And it's a thickening in the capsule there, and when you pivot, shift the knee and almost dislocate the lateral compartment, you can rip off the avulsion of that proximal tibia with a bit of the capsule holding it.
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So it's just above Gerdy's tubicle.
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And that's an association with the anterior cruciate ligament injuries.
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Always, yeah, always means the cruciate's been stretched beyond repair or ruptured completely.
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Now, obviously treatment may vary depending on when the patient presents and perhaps you can actually outline how it may vary.
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Certainly if they present acutely, it may be different to someone who's actually several weeks down the track.
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Does that make a big difference to yourself?
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Yeah, I think what the patients need to be obviously educated and well aware of what's ahead of them.
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And you don't want to operate on anyone for anything if they're not well informed about their expectations on their rehab, particularly with ACL surgery.
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or ligament surgery because the rehab's sort of half the problem and the surgery's the other half and if they don't recognize that or they don't have any idea about that then it can become a disaster after surgery.
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So a little bit of education is good.
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The old treatment for ACLs was wait until they had no swelling and full range of motion and You retested them and then operated when they were fit and healthy.
00:21:45.303 --> 00:21:52.532
Most people don't do that now because the ACL rehab early on promotes movement rather than stiffness.
00:21:52.653 --> 00:21:57.722
So we don't see the arthrofibrosis and stiffness problems by operating early.
00:21:57.722 --> 00:22:06.532
So most people want to get on and have it treated in a fairly timely manner because they don't want to wait three months and then have 12 months off.
00:22:08.252 --> 00:22:19.262
So if they've been educated and I always want to send them down to have a session with the physios for that because physios are good at explaining the rehab better than we are.
00:22:20.462 --> 00:22:30.962
If they've had an education session with the physios and they seem like they understand the problem and they can move their knee fairly well then I'd go ahead with early surgery.
00:22:31.593 --> 00:22:42.083
But if they're not educated or they don't seem to be aware or If they're a bit stiff, I would make them wait for a few weeks until they've got better educated and better movement.
00:22:42.413 --> 00:22:47.083
So then you've got the other issue is the collateral damage and meniscal damage and fractures.
00:22:47.163 --> 00:22:54.163
So, fractures and repairable meniscus injuries should be treated early.
00:22:54.643 --> 00:22:57.363
You don't want to leave them for a month or two to get movement.
00:22:57.383 --> 00:22:58.833
So, that might sway.
00:22:58.883 --> 00:23:01.432
If they've got that other collateral damage, you'd go a bit earlier.
00:23:02.542 --> 00:23:08.923
What about if they've got a fracture then, would you wait until that had healed then treat it or would you go in early in that scenario too?
00:23:09.512 --> 00:23:21.482
If it was a stable fracture you might leave it and treat conservatively till that heals, particularly if it's a crack around where you want to put a tunnel or put a fixation device for your ACL.
00:23:22.083 --> 00:23:27.613
But if it's an unstable fracture or displaced fracture then obviously you'd fix that and probably do the ACL.
00:23:28.367 --> 00:23:31.238
at the same time if it was possible to do that.
00:23:31.998 --> 00:23:34.998
What about the role of conservative treatment in cruciate injuries?
00:23:35.288 --> 00:23:39.337
Is that still a role nowadays in the current sports person or is that sort of going out the window?
00:23:39.647 --> 00:23:42.357
I think it's had a little bit of resurgence.
00:23:42.877 --> 00:23:52.867
There's a study out of Sydney on bracing in flexion for a number of weeks and then slowly getting their extension back because in flexion, the ACL.
00:23:53.827 --> 00:23:55.278
is not under any tension.
00:23:55.678 --> 00:24:08.907
And if you pick patients with perhaps high grade partial tears or people where the ligament's still sitting in a good position, then they are getting some of them to heal with that treatment.
00:24:09.847 --> 00:24:15.157
I don't think they're getting back to sport any quicker, but they may get away without needing a reconstruction.
00:24:15.157 --> 00:24:28.873
But the treatments, six or eight weeks, I think, in a flexed knee brace, using a scooter, to get around and crutches and then another six or eight weeks getting walking again and then another three or six months of physio strengthening.
00:24:28.873 --> 00:24:39.823
So it is possible probably with a high grade partial tear or a tear where the fibers are still sitting in a good position.
00:24:40.712 --> 00:24:46.303
In the past, it's come and gone a little bit, it's making a little bit of a comeback at the moment.
00:24:48.962 --> 00:24:57.712
Do people need to have a cruciate reconstruction because of to prevent arthritis or to prevent instability episodes, or what's the main reason that people present for a cruciate?
00:24:59.103 --> 00:25:00.633
Well, it's for knee stability.
00:25:01.373 --> 00:25:15.452
So, most people, if they stop playing directional change sport, probably don't need an ACL for cycling, jogging, swimming, daily activities.
00:25:16.323 --> 00:25:33.742
Some people are unstable even with daily activities, they can have bad shape of their bones, maybe meniscus missing or some slight damage to other ligaments, and they just have instability with daily activities, loading a dishwasher and walking around the kitchen.
00:25:34.603 --> 00:25:36.292
So it's all about instability.
00:25:36.292 --> 00:25:48.778
If you have instability, it causes pain and swelling every time it gives way, which then Restricts your lifestyle and also it causes damage every time it gives way.
00:25:48.857 --> 00:25:56.327
So if you get torn cartilage or chondral damage from recurrent instability, you'll end up with arthritis.
00:25:56.367 --> 00:25:57.028
There's two things.
00:25:57.028 --> 00:26:01.798
One is if you're really wobbly and unstable, good to have a ligament put in.
00:26:02.468 --> 00:26:06.167
If you want to play twisting and turning sports, then keep playing those sports.
00:26:06.178 --> 00:26:07.647
It's good to have a ligament put in.
00:26:08.478 --> 00:26:12.978
And To prevent arthritis, it's an indirect prevention.
00:26:13.238 --> 00:26:16.768
If you have a stable knee, you'll get less cartilage damage.
00:26:17.178 --> 00:26:20.077
And if you have less cartilage damage, you'll probably have less arthritis.
00:26:22.048 --> 00:26:27.817
So we've already mentioned in passing, the medial collateral is usually treated non operatively.
00:26:27.867 --> 00:26:36.127
Are there any role, is there any role for repairing a medial collateral ligament as well as when you're doing an anterior cruciate as well, or even isolated a medial collateral ligament injury?
00:26:37.178 --> 00:26:54.998
There is again it's a bit like the ACL, if your medial collateral's displaced so far that it's got no chance of healing, sometimes they can rupture and stick inside the joint or they can move a centimetre or two away from their attachment or they can get stuck up above a hamstring.
00:26:54.998 --> 00:27:00.417
So if they're very displaced and they don't look like they're in a good position then you might repair early.
00:27:01.228 --> 00:27:03.627
But most of the others will heal well with.
00:27:04.208 --> 00:27:05.188
Brace therapy.
00:27:05.657 --> 00:27:06.857
There's a good blood flow.
00:27:07.157 --> 00:27:09.307
If you get them early, they'll heal well.
00:27:09.307 --> 00:27:12.377
If it's late, there's no healing potential.
00:27:12.397 --> 00:27:15.087
So after six weeks, you've probably got to repair them.