Core Lecture Knee Orthopedics

8/17/2019 Core Lecture Knee Orthopedics

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The Knee: Core Lecture

Class IC3 January 2016

Lecturers Iain Feeley

Richard DowneyMartin Kelly

Lauren Tiedt


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Learning Objectives

After this lecture you should be able to: Obtain a structured musculoskeletal history from a pat

presenting with knee pain

Demonstrate a structured comprehensive examinationknee joint

Be able to explain aetiology prognosis treatment and

complications of treatment for common knee patholog Demonstrate a structured approach to the assessment

radiographs of the knee


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Basics

Largest and most complicated joint in the body !omplex pivotal synovial hinge joint

"nee # $enu

%ost commonly replaced joint in the &'A "nee OA most common joint disease

%ost common arthroscopic procedure


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Anatomy

!onnects the femur to the tibia

%ade up of medial and lateral condyles of femurattaching to tibia condyles

$liding joint b(t the patella and patellar surface of thefemur

)inge joint b(t the femur and tibia

!overed with a layer of hyaline cartilage

*ibula is +O, part of the knee joint


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Anatomy - Capsule

-oint capsule attaches tothe margins of thearticular surfaces andsurrounds the sides andposterior aspect of the

joint

,he front the capsule isabsent which permits thesynovial membrane topouch upward beneaththe .uadriceps tendon


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Anatomy - Ligaments

/atellar Ligament 0,endon1 !ontinuation of central portion of the .uadriceps tend

*rom inferior patellar border to tibial tuberosity


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Anatomy - Ligaments

%edial !ollateral Ligament Broad2 3at band

*rom medial femoral condyle to medial tibialshaft

/rovides stability against valgus stress

4t is 5rmly attached to medial meniscus

+B %!L tears may also injure medialmeniscus


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Anatomy - Ligaments

Lateral !ollateral Ligament !ordlike

*rom lateral condyle of the femur to 5bular head

/rovides stability against varus stress


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Anatomy - Neurovascular

+erve 'upply *emoral2 obturator2

common peroneal2 andtibial nerves 0terminalbranches of the sciaticnerve1

Blood 'upply ,he popliteal artery and its

geniculate branches form arich anastomosis aroundthe knee joint


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History

/ain 'O!6A,7' model

8hat does it feels like9 'harp: muscle strain(tear2

fracture

Dull: OA2 6A

Achy: OA2 6A


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History

8hat were they doing when the pain came on9

Did they fall9 fractures2 muscle tears2

haematomas2 ect

/laying sports9 %uscle sprain2 ligament

sprain(tear

/rolonged exercise9

OA

$radual vs sudden9

6A2OA vs ,rauma2 gout

Did they hear a pop9 Ligament injury


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History

)ow bad is it and is it always there9

Always ask the patient to score their painbased on their pain threshold

OA is worse as the day goes on

6A present with morning sti;ness

Ligament injuries are worse when youwalk(bend the knee

,endonitis is worse when jumping2 climbingstairs2ect

Bursitis becomes achy while walking2 worsewith stairs


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History

)ow does the pain a;ect their daily

life9 )ow far can they walk9

Di


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History

/%)x:

)ave they had any childhood kneedisease9Osgood 'hlatter=s disease

)ave they previously injured theirknee or had problems with their knee9/revious knee fractures may lead to OA

/revious bursitis may become aggravated

/revious ligament damage is at risk of beingdamaged again

Any other illnesses94s the patient 5t for surgery if they need it9

Do they need to be reviewed by respiratory2cardiology

8ill they be at risk of infection9 D%2 />D


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Social History

8ho will take care of them when

they go home post operatively9

8ill they need to go to a step downfacility9

Does O, need to asses their home9 'tairs2 bathroom access

Are they liable to fall at home999

Do they smoke9 4f so they are at a higher risk ofinfection2 wound breakdown

Do they play sports professionally9 4f so they may need earlier surgery2

more aggressive physio


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Examination

8atch the patient walk into the room and sit down

? walking aid2 limp2 uncomfortable gait

4nspect knee for scars2 swelling2 obvious deformity

/revious scars: ligament

repair2 ,"6 'welling: gout2 OA2 bursitis


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Palpation

*eel for .uadriceps wasting

*eel for a warmth and synovial swelling

/atellar ,ap 0joint e;usion1:? rest one hand over .uads muscle and milk down any 3uid into the

hand over lower part of .uads and compress the suprapatellar bursa whand gently push the patella down

? the sign is positive if the patella is felt to sink and taps the under

Bulge sign: detects small e;usion? compress the suprapatellar pouch? run your 5ngers on one side of the patella and then the other? notice any bulge on the side not being compressed


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Movement

,est 3exion 0@ deg1

,est 7xtension 0 deg1


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Check staility

%!L: >algus stress

L!L: >arus stress

A!L: !heck for excess anterior translation of tibiain relation to femur

Anterior drawer test Lachmann=s test /ivot shift test 0under $A1

/!L: /osterior translation of tibia in relation tofemur

/osterior lag sign /osterior drawer test


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Meniscii

-oint line tenderness mostsensitive for meniscalinjury

%c%urray test

Apley test

!ompression Distraction


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!o "inish

+eurovascular exam

O;er to examine the jointabove and joint below

,hank the patient

Any speci5c imaging orinvestigations re.uired9


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A#ult Pathology - $steoarth

OA knee most common joint disease

6evise pathogenesis: initial changes in articular cartilage

5brillation of cartilage vertical clefts

exposure of subchondral bone

eburnation

67% /rimary and 'econdary OA


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67% C cardinal 6 signs9


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-oint space narrowing


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'ubchondral sclerosis


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'ubchondral pseudocystformation


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'ubchondral pseudocystformation

$steophytosis


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!onservative ,reatment8eight loss

%odify daily activities2 walking aids

7xercising within the limits of pain should be encouraged

/hysiotherapy

Analgesia: aspirin2 paracetamol +'A4D'

'urgical ,reatment

Arthroplasty8hen patients have severe pain2 nocturnal pain2 pain at rest2 and severely restri

Arthrodesis6arely used in OA2 sometimes used in pt too young for hip replacement

Osteotomy&tilised to realign deformities and spread the transmitted loads more evenly in y


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A#ult Pathology % &heumatoArthritis !hronic systemic disease of unknown aetiology

!haracteriEed by chronic symmetric in3ammation of the joints

>ariable extra articular manifestations # eyes2 skin2 lungs etc

*F% C:@

$enetic predisposition with )LA

a(w low grade fever2 loss of appetite2 malaise2 fatigue


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A#ult Pathology % &heumatoArthritis 'oft tissue swelling

-uxta?articularosteopaenia

%arginal erosions


Deformity

)ands are oftena;ected earliest


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A#ult Pathology % &heumatoArthritis %edical ,reatment:

*irst Line ,x ? +'A4Ds 6educe sti;ness and synovitis2 improve mobility

'econd Line ,x ? D%A6D'

$old salts2 penicillamine2 immunosuppressants 0methotrexate12 infliximab 0anti tnf?

,hird Line ,x ? !orticosteroids

'ystemic or 4ntra?articular in accessible joints

'urgical ,reatment 7arly in disease process before signi5cant radiographic changes # synovectomy

!an be perfomed arthroscopically

Advanced disease

-oint replacement 0Arthroplasty1

6estores pain free function

-oint fusion 0arthrodesis1


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$steoarthritis an# &heumatArthritis

h l i


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!rauma'Pathology % Menisca(n)uries ,hree common meniscal problems

!ongenital discoid meniscus

$enerally presents in childhood

Longitudinal meniscus tears

Occur in young adults2 rarely in females

)oriEontal cleavage tears

Occur in both sexes in middle age

,he periphery of each meniscus has a tenuous blood supply

,he central part of the meniscus is nourished by di;usion only 4t is thus incapable of repair


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A#ult'Pae# Pathology % *iscoi#Meniscus

4n the early stages of development the menisci are disc shap Later2 the central portion of the disc is resorbed2 producing the norma

con5guration

4n some people this process fails to occur

,he resulting solid meniscus tends to detach at its periphery

4f the meniscus is relatively stable Arthroscopic resection of the central portion

/artial meniscectomy

4f meniscus is too unstable Arthroscopic total meniscectomy is often re.uired


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!rauma'Pathology% Meniscal !e

O(7: 7;usion

%uscle wasting from long term meniscalinjury 0pt won=t fully extend so >%Obecomes wasted1

Localised palpable tenderness

%ay have decreased extension2 pain on full3exion

/ositive %c%urray(Apley grind test

! 'P th l M i l


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!rauma'Pathology% Meniscal!ears Longitudinal tear is by far the most common types of meniscal inju

Occurs in the young adult # traumatic +ormally degenerative in elderly

factors are generally found to have been present ,he knee was weight bearing

4t was 3exed

4t was twisted 0ie2 subject to rotational stress1

%ost commonly the tear involves the mid?portion of the m 4f the tear is extensive2 the inner limb of the torn meniscus may

displaced # Bucket Handle tear

4n others2 further transverse tearing ? Parrot Beak tear


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!rauma'Pathology% Meniscal !e

Arthroscopic resection of the torn portion ofthe meniscus

%ost popular method of treatment6esect back to a stable rim

Open arthrotomy%ainly reserved for failed arthroscopic resections

%eniscal repair6eserved for peripheral tears in younger patients

/hysio post op is essential

! 'P th l Li


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!rauma'Pathology% Ligamen(n)uries A!L 4njury

%ost common ligament to be injured

%ost fre.uent cause of acute haemarthrosis

4t can be torn in isolation Often2 other structures injured simultaneously

%echanism of 4njury 7xternal rotation of the tibia on the femur combined with an abduction for

/t gives a history of signi5cant injury Often with the sensation of something giving within the knee or an audible Hp

4nvariably followed by a rapidly forming haemarthrosis

'ome patients present late !omplain of feelings of instability

4ncidents of giving way followed by e;usion

!an be di


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!rauma'Pathology% ACL (n)u

Anterior Drawer ,est

Lachmanns ,est


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!rauma'Pathology % ACL (n)u

!onservative ,x

"nee 'upports Basic

)inged

'tabilised

4ntensive /,

'urgical ,x

'urgery is reserved for paduring normal activities hsymptoms of instability

!ommon reconstructive p

use either part of the pateligament or woven syntheimplants


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!rauma'Pathology % PCL (n)u

%uch less common than A!L injury

Often found combined with other ligamentous injuries

%echanism of 4njury *all on the 3exed knee

Dashboard impaction during an 6,A

%ay be overlooked unless the possibility of its occurrence is kmind and a careful examination is performed

8hen the knee is 3exed2 the tibia usually sags backwards unfemur

!omparison with the opposite side is essential


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!rauma'Pathology % PCL (n)u

4n acute cases2 conservative treatment is often advocate

4ntensive .uadriceps exercises can produce good results

/ersisting instability can lead to severe and rapidly progr 4f conservative measures fail2 surgical ligament reconstruction m

the risk of serious complication

/ositive sign on the /osterior draw test

4nstability of the joint

Associated with the feeling of the knee giving way

!rauma'Pathology Collater


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!rauma'Pathology % CollaterLigament (n)ury !ommonly injured

%!L is more fre.uently a;ected

6e.uires signi5cant force

'porting tackle Blow to the side of the leg from a motor vehicle

4n a number of cases there are associated fractures tibial plateau

!rauma'Pathology Collater


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!rauma'Pathology % CollaterLigament (n)ury64!7

6est from training

8ear a hinged knee brace to support the joint in severe

8ear a heat retainer after the acute phase

Apply a support bandage or plaster cast

Aspirate the joint if e;usion present

Apply sports massage techni.ues

/hysio

&'( laser therapy

'urgery

Pathology &etropatellar Pa


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Pathology % &etropatellar PaSyn#rome !haracterised by ill?localised patellar pain

+o speci5c features apart from being made worse by prolongedby walking on slopes or stairs

/ain is usually not severe but may sometimes limit activities

'ometimes a small joint e;usion # knee may give way

!ommon in adolescent and young females

$enerally self limiting

+o clear cut pathological lesion Deep layers of the articular cartilage of the patella may degene

0Chondromalacia patellae1

Pathology % &etropatellar Pa


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Pathology % &etropatellar PaSyn#rome 4nvestigation

?6ays which should include a skyline 0tangental1 vie %ay reveal maltracking of the patella

,reatment $eneral advice is given to avoid activities which are k

aggravate the condition

Juadriceps building exercises

Pathology % $sgoo#-Schlatte


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Pathology % $sgoo#-Schlatte*isease !ommon problem in the young adolescent

4t is a traction apophysitis !an be bilateral

!auses mild pain which is worse after exercise

,ypically2 the tibial tubercle is tender and prominent "nee movements are una;ected

Pathology % $sgoo#-Schlatte


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Pathology % $sgoo#-Schlatte*isease A lateral radiograph shows displacement or

fragmentation of the apophysis

,reatment is generally symptomatic as thecondition is self?limiting

6estriction of activity may be su


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Pathology % $steochon#ritis*essicans !ondition in which a small fragment of bone just

to the articular surface is rendered avascular Along with the healthy cartilage capping it2 it become

detached from the healthy structures

!an form a loose body

Aetiology uncertain !ontact between the femoral

condyles and tibial spines or

A!L may be signi5cant

Pathology % $steochon#ritis


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Pathology $steochon#ritis*essicans MN of defects involve the lateral aspect of the medial f

condyle %ay be bilateral

4nitially it is symptom free Later it may cause mild pain in the joint and an e;usion

Loose body may cause locking of the joint

Pathology % $steochon#ritis


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Pathology $steochon#ritis*essicans Diagnosis

Often con5rmed by routine x?rays of the knee 'pecialised tunnel projections # show intercondylar area

Arthroscopic assessment

)elpful in deciding whether the fragment is becoming detached and likely to fobody

,reatment *ragment remains in situ

Observation with serial x?rays

%obile fragment

Area may be drilled # promotes healing

Defect may be pinned back ( loose bodies removed

$ th #i ( t ti


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$rthopae#ic (nterventions

,otal "nee 6eplacement

*emoral and ,ibial components /olyethylene liner

$ th #i ( t ti


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$rthopae#ic (nterventions

&nicondylar "nee 6eplacement "nee is divided into medial2

lateral2 and patellofemoral

@M?MN of patient have wear onlyin one compartment

/ros: smaller incision2 easier

rehab2 shorter hospital stay2 lessblood loss2 lower infection risk

!ons: less reliable long term

/atellofemoral 6eplacement

C li ti


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Complications

4mmediate early late

$eneral speci5c

S i, C li ti


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Speci,c Complications

*emoral notching(peri?prostetic

fracture /eroneal nerve palsy

0tourni.uet(retractor1

>ascular complication

7xtensor mechanism rupture 'ti;ness(limited 6O% post op

4nfection

&nhappy patient

J ti


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Core Lecture Knee Orthopedics

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