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Cedera Sendi
Cedera SendiRizki RahmadianBagian Bedah FK Unand/ RS. Dr. M. Djamil PadangSendi Lutut
TulangPatella
Tibia
FibulaSendi Lutut
LigamentAnterior Cruciate Ligament (ACL)Posterior Cruciate Ligament (PCL)Medial Collateral Ligament (MCL)Lateral Collateral Ligament (LCL)Popliteal Ligament
Sendi LututMeniskus
Crescent shape
Fibrocartilaginous
Vascularized : arteri genikular lateral dan medial
20-30% meniskus medial dan 10-25% meniskus lateral
Medial : C shape
Lateral : sirkulerAnamnesis dan Pemeriksaan FisikMekanisme InjuriPosisi sendi lutut saat terjadi cederaWeight supportingVarus atau valgusCedera kontak atau non kontak
Cedera non kontak dengan sesasi bunyi pop : cedera ACLCedera kontak dengan sensasi bunyi pop : cedera ligament kolateral, meniskus atau frakturThe Terrible triad of ODonoghueMedial meniskus tearRuptured of ACLRuptured of medial collateral ligament
HemarthrosisPenyebab hemartrosisRuptur ACL PCLTear MeniskusFraktur osteokondralRobekan kapsul sendi
PembengkaanEvaluasi lengkap pembengkakanIntra atau ekstraartikulerLokasi pembengkakan ekstraartikuler
Derajat pembengkaan : mild, moderate, severeAkut atau sub akut
Cedera Sendi LututLesi osteokonralRobekan meniskusRuptur Cruciate LigamentRuptur collateral ligamentLesi osteokonralKnee injuriesHunter 1743From Hippocrates to present age,it is universally allowed thatulcerated cartilage is a trouble some thing & that once destroyed, is not repaired
Type IV defect
CartilageCartilage is marvelous: tough, elastic, durable.
If normal, it will last lifetime.But if damaged; even normal activity lead to erosion of joint surface.13protecting the ends of the bones from the stresses placed on them.
Penyebab Kerusakan Rawan SendiCedera olah raga
Trauma
Keadaan patologisOCD
ICRS Arthroscopic ClassificationLesion Thickness
Grade 0: Normal
Grade I: Superficial fissures
Grade II:50% depth but not thru subchondral plate.
Grade IV: lesion thru subchondral plateOCD lesionsAVN lesionsTreatment optionsSome light is now seen at the end of centuries old dark tunnel. Benign neglectDebridementPridies perforationsAbrasio ArthroplastyKevins Morselized osteochondral mixtureSteadmanns MicrofracturePeriosteal GraftingPerichondrial GraftingOsteochondral AllograftOsteochondral AutograftMosaicplastyACIBiomaterials
Tujuan PenatalaksanaanMengembalikan permukaan tulang rawan
Regenerasi hyalin atau hyalin likeIdeal.
Jika tidak menungkinkan, regenerasi fibrocartilageProperti biomekanik tidak bagusTingkat kerusakan tinggiTidak memungkinkan aktivitas beratTidak memerlukan tindakan dan observasiLesi < 1 cm
Dokumentasi
Monitoring ketat
Shelbourne et al. American Academy of Orthopedic Surgeons. Annual meeting. 2002.MicrofractureMenghasilkan fibrocartilage
Bertahan sampai 10 th
Steadman et al. J of Knee surgery: 2004: vol 17.1 Jan: 13-17. 20This marrow-stimulating procedure is developed by Steadman and associates8. They proposed that all injured and unstable cartilage should be removed and a circumferentially stable area of the defect is created. This area should be perforated with specially designed Arthroscopic pecks. These are designed to fracture the subchondral bone plate at regularly spaced intervals. These pecks can be of various angles to give access to various areas of joint. This allows access and migration of bone marrow stem cells to the articular surface. It is advocated as the first line of treatment for most small (1-2 cm), contained lesions, and if it fails then more invasive techniques may be done. Studies in horses indicate repair is mainly fibrocartilage. However, little or no long term human biopsy work has been performed.Steadmans published long term results for 81 cases having an isolated, full-thickness, small degenerative defect of the condyle; with average age of 49 years. There were no other concomitant lesions, and limb alignment was normal. Pain, swelling, limping, walking, stair-climbing and descending, level of sport, and activities of daily living all improved. Patients with lesions in all 3 compartments of the knee also improved. 13 patients (15%) had subsequent arthroscopic lysis of adhesions for pain or stiffness, and 5 had revision microfracture or conversion to a total knee replacement. This study was criticized for its lack of a control group and its very select group of patients enrolled. Authors emphasized the rigid adherence to the technique of microfracture as well as to the postoperative treatment. Patients must receive CPM for 8 hours a day for 8 weeks, and should achieve partial weight bearing. If the patient meets criteria, he may return to sports in 4 months.
MosaicplastyOsteochondral graft selinderDari permukaan NWBKe permukaan WB
Indications:Non degenerative1.5 to 4 cm2IsolatedAbsolute contraindications:Age > 50Size > 4-8 cm2Depth > 10 cm.
Hangody et al. JBJS-Am. March 2004; 86-A supp 1: 65-72.21Hangodys Mosaicplasty831 cases
12-13 years of F/U
Good/Excellent results92% femoral condyle87% in Tibial resurfacing79% in patella/ Trochlea
Donor site morbidity: 3%
Natural HistoryType of cartilage:Hyaline or likeLife: medium to long termgood resultsHangody et al. JBJS-Am. March 2004; 86-A supp 1: 65-72.22MosaicplastyThis procedure is developed by Hangody and colleagues13. This technique involves obtaining small cylindrical osteochondral grafts from the minimal weight bearing periphery of femoral condyles at the level of patello-femoral joint, and transplanting them to prepared defect sites on the weight bearing surface. His study is based on 12-13 years of extensive animal, histological research and promises hyaline or hyaline like regeneration of the small and medium size defects. So far, 831 cases have been operated by him and his colleagues. They achieved good to excellent results in 92% cases with femoral condyle defects, 87% in Tibial resurfacing, 79% in patellar/ Trochlear mosaicplasties. Donor site morbidity was 3% when measured with Bandi score system14. The donor holes get filled by cancellous bone upto the surface, capped by fibrocartilage in eight weeks. Fibrocartilage coverage of the donor holes is acceptable gliding surface for the areas that bear less weight or no weight. Four deep infection and 36 painful post op heamarthrosis were reportedAutologous chondrocytes implantaion
Cost: 11000$ only2 tahap operasiMenghasilkan kartilago hyalin
Peterson L. 2001; 391:S337-S348.23Autologous Chondrocytes implantationThis method is one of the most interesting and perhaps, most controversial form of treatment. This is developed by Swedish researchers at Sahlgrenska University Hospital15. The technique of implanting cultured chondrocytes is very expensive at present (approximately $11,000). In addition, two surgical procedures are required. First is harvesting a plug of articular surface and then culturing the chondrocytes; the second is an open arthrotomy to implant the cells. Cartilage defect is debrided to healthy tissues, and a periosteal patch harvested from proximal Tibia is sutured over the defect. The cultured cartilage cells are than implanted between subchondral bone and the sutured periosteum. The second procedure has all of the risks associated with open surgery. Hypertrophic periosteal patches, unevenness, adhesions, lab dependency are other disadvantages of this procedure. ACI is not recommended for use in patients with known history of allergy to the gentamicin, in patients with sensitivities to materials of bovine origin, who have an unstable knee, or who have abnormal weight distribution within the joint, and in patients with grave pathological disease of the same limb. Any instability of the knee or malalignment of the joint should be corrected before or concurrent with ACI. Use in children has not yet been assessed.
Ruptur meniskusKnee injuriesANATOMPerimeniscal capillary plexus (PCP) : vaskularisasi menuskus dari perifer
Mekanisme InjuriRotasi akut pada sendi lutut yang menerima beban tubuh
Robekan degeneratif terjadi akibat cedera berulang
Tipe Robekan
Pemeriksaan FisikNyeri saat menerima berat badan tubuh dan rotasi sendi lutut
Nyeri tekan pada garis sendi
Gejala mekanik : popping, giving-way, pembengkakan, locking
Gelaja hilang dengan melakukan reduksi fragment meniskus secara manual
Pemeriksaan FisikMcMurray testApley test etc
IMAGING (MRI)
PenetalaksanaanKonservatifOperatif:Open techniqueInside-outOutside-inAll insideMeniscus transplantationPartial meniscus replacement
SURGICAL TECHNIQUES
Open techniques
An inside-out technique using vertical sutures
An outside-in technique using horizontal sutures
An all inside using a meniscal fixation device A 10mm meniscal fixation device (Biostinger)
Cedera Anterior cruciate ligamentKnee injuryACLAnatomiACL adalah satu dari 4 ligamentum yang menstabilkan sendi lutut
Melindungi meniskus dan permukaan rawan sendi
ACL mencegah translasi anterior tibia dan internal atau eksternal rotasi tibia terhadap femur
Mekanisme CederaCedera ACL terjadi ketika tekanan yang besar dari bagian anterior saat posisi lutut iperekstensi
Robekan biasanya terjadi pada bagian tengah ligament, bagaimanapun robekan pada bagian proksimal atau distal dapat terjadi
DiagnosisGejala klinis cedera ACL AnamnesisKetahui mekanisme cederaSesasi pop dan nyeri
Excessive swelling with knee effusion
Decreased range of motion (ROM)
DiagnosisDiagnosisHistory and presentation + Lachmans or Anterior DrawerImagingX-ray (avulsion)MRIHemarthrosis (joint aspiration)Appropriate referralDrawer Sign
Anterior Cruciate Ligament Rupture
Treatment RehabilitationPrehab (Gold-standard)Implemented immediately after diagnosisDecrease pain and swellingIncrease ROM, quad strength, and proprioception >90% of contralateral legPrehab allows for quicker post-operative return to ADLs and physical activityRehabProgression varies depending on graft choiceAlso focuses on decreasing pain and swelling, while increasing ROM, strength, and proprioception
Treatment Graft choices (4 most commonly used)Achilles tendon allograftHamstring tendon autograftIpsilateral BPTB autograftContralateral BPTB autograft
Surgical TechniqueSurgical TechniqueHarvest graftExpose jointRemove damaged ACL, clean, and make room for new ACLDrill tibial and femoral tunnelsInsert new ACL with bone plugs (button approach shown)
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