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)
Thank You
