3 - Acute Injuries to Knee Complex Flashcards
What can joint inflammation be the result of? (5)
- Osteoarthritis
- Rheumatoid Arthritis
- Joint Sepsis
- Trauma
- Post-Surgery
Knee joint effusion as a result of joint inflammation causes ___
Arthrigenic Muscle Inhibition (AMI)
What does AMI cause?
ongoing reflex inhibition of musculature, especially the quadriceps muscle group
How many mL of fluid can lead to muscle inhibition?
60
What three things are assessed in the evaluation procedures of joint inflammation?
- Joint Effusion
- ROM
- Muscle Strength, Endurance, and Speed
What tests can be done to assess joint effusion? (2)
- Fluctuation
2. Ballotable Patella Test
How is ROM assessed? (2)
- Actively
2. Passively
When would use of a goniometer be required when doing ROM assessment?
to document ROM if plan to use as outcome measure
What test is primarily used to assess muscle strength, endurance, and speed?
Knee musculature MMT
What is the Etiology of Patellar Restrictions?
Usually seen after prolonged periods of immobilization, post trauma or following surgery
What is the primary Clinical Symptom of Patellar Restrictions and what is it due to?
Limitation in knee flexion most common due to lack of inferior glide.
What is a rare Clinical Symptom of Patellar Restrictions and what is it due to?
Although rare, lack of superior glide can cause extensor lag.
What is a key point when evaluating Patellar Restrictions?
If patient has restricted knee ROM, always check patellar glide first!
Of all knee ligaments, most common injured is the ___
Anterior Cruciate Ligament.
As a result, ACL has been extensively studied of all the knee ligaments.
Which ligament has fibers that have a direct attachment to the Medial Meniscus?
deep fibers of Medial (Tibial) Collateral
What are the two posterior ligaments?
Oblique and Arcuate Popliteal
What are the two cruciate ligaments?
Anterior and Posterior
What is the ACL divided into?
2 Bundles based on work by Girgis et al.
What are the two ACL bundles?
- Anteromedial (AMB)
2. Posterolateral (PLB)
How are the bundles of the ACL defined?
by tibial attachment
What other model has been defined for the number of bundles?
A 3-bundle model
What is the third bundle in the 3-bundle ACL model?
Intermediate Bundle
What is the ACL enveloped in?
Synovial Membrane
The ACL is placed (intra/extra)-articular BUT (intra/extra)synovial throughout its course.
The ACL is placed INTRA-articular BUT EXTRAsynovial throughout its course.
Knee instabilities caused by traumatic injury to either ligament or capsular tissue are classified as (2)
- Instabilities occurring in a SINGLE PLANE or STRIAGHT
2. Instabilities occurring in MULTIPLE PLANES or ROTATORY
Single OR Multiple Plan instabilities defined during the physical examination by
the direction of abnormal tibial plateau displacement
Initially, the medical community only recognized
single-plane instabilities
Classic definition of ligament injury in the 50’s through 70’s was the____
“Unhappy Triad” - Injury to the ACL, MCL, and Medial Meniscus
In the early 80’s, physicians began to understand that most injuries occurred in
multiple planes
What was the first instability recognized?
Anterior-Medial
What are the tissues involved with Anterior instability?
ACL, Anterior Capsule
What Clinical Tests are done for Anterior Instability?
Lachman’s, Anterior Drawer Test
What are the tissues involved with Posterior Instability?
PCL, Posterior Capsule
What Clinical Tests are done for Posterior Instability?
Posterior Drawer Test, Gravity Test
What are the tissues involved in Medial Instability?
MCL, Medial Capsule
What Clinical Tests are done for a Medial Instability?
Valgus Stress Test (full extension 1st; then in 25 degs of flexion)
What Clinical Tests are done for a Lateral Instability?
Varus Stress Test (full extension 1st; then in 25 degs of flexion)
What is the Direction of a Anteromedial multiplane instability?
Medial tibial plateau moves into an anterior and externally rotated direction with respect to the femur.
What are the Involved Structures in a Anteromedial multiplane instability?
- ACL
- Medial Capsule
- MCL
What Tests are done for a Anteromedial multiplane instability?
- Lachman’s Test
- Valgus Stress Test
- Anterior drawer with tibia externally rotated
What is the Direction of a Anterolateral multiplane instability?
Lateral tibial plateau moved in an anterior and internally rotated direction with respect to femur.
What are the Involved Structures in a Anterolateral multiplane instability?
- ACL
- Lateral Capsule
- Arcuate Ligament
- Posterior Aspect of IT Band
What Tests are done for a Anterolateral multiplane instability?
- Lateral Pivot Shift, Flexion or Jerk test
2. Varus Stress test (anterior drawer with tibia internally rotated)
What is the Direction of a Posterolateral multiplane instability?
Lateral tibial plateau moves in a posterior and externally rotated direction with respect to femur.
What are the Involved Structures in a Posterolateral multiplane instability?
- LCL
- Posterior Capsule
- Acrcuate Ligament
- Popliteus Tendon
What Tests are done for a Posterolateral multiplane instability?
- Posterior Drawer Test
2. Gravity or Posterior Sag Test
Unless you actually see the injury occur, difficult to know if the injury is
anteromedial vs. anterolateral
What is a KEY THING to establish in HX?
Was direction of injury anterior OR posterior?
Always keep in mind - irrespective of direction - most of time instability will be ___
multi-directional
How many Ligament and Capsule Injury Grades are there in the classification and what severity do they correspond to?
Grade I (mild)
Grade II (moderate)
Grade II+ (severe)
Grade III
What happens in a Grade I (mild) ligament and capsular injury?
Microtears with no apparent laxity
What happens in a Grade II (moderate) ligament and capsular injury?
- 1/3 to 2/3’s of ligament/capsule damaged
- 0-5mm joint gapping with FIRM end-feel
What happens in a Grade II+ (severe) ligament and capsular injury?
-5-10mm joint gapping with SOFT end-feel
What happens in a Grade III ligament and capsular injury?
- 2/3’s to complete rupture of ligament/capsule
- Greater than 10mm gapping with NO end-point
What is the 1st indication for surgery?
- Acute traumatic injury with involvement of one or more ligaments and severe instability
What is the 2nd indication for surgery?
Chronic knee instability secondary to old traumatic injury with poor conservative outcome
What is the 3rd indication for surgery?
Buckling or “giving way” of the knee plus pain
What are potential problems with no repairing?
Recurrent episodes of knee instability or “giving way” can lead to progressive osteoarthritis as well as damage to menisci and articular cartilage.
Key question is “to repair or not to repair.” General Rule - ___
The younger the patient and higher the level of demand on the knee joint, the greater the risk for joint damage.
What are surgical treatment of choice for ACL reconstruction? (2)
Intraarticular Reconstructive Repair
- Arthroscopic
- Arthrotomy
What are the Tissue choice for repair types? (2)
- Autograph
2. Allograph
What is an Autograph tissue?
Material obtained from the patient
What is Allograph tissue?
Freeze-dried material obtained from cadaver
What are the most common donor sites for Allograph tissue?
patellar tendon or semiteninosis with or without gracilis multistrand graft
T/F: Allographs can have higher failure rates.
True
What indicates that Allographs can have higher failure rates than Autographs?
Results from animal studies indicate delayed soft-tissue healing and graft remodeling issues not seen in autographs.
Are Allograft failure rates higher in younger or older patients?
Younger (
What are the advantages of allograft? (2)
elimination of graft harvest issues and decreased surgical time.
When is the tissue graph strongest?
on the day of surgery
What happens to graft material used for the repair immediately?
undergoes necrosis
The graft materials will at best regain __% of original strength?
80%
What implication does the graft materials only regaining a percentage of original strength have?
Why it is important to select materials that are initially stronger than the ACL.
How long can it take up to for graft to attain maximum strength?
12 to 14 months
What is the most commonly used autograft material that has been considered the “Gold Standard” for ACL repair?
Patellar Tendon (central 1/3)
What are the advantages of using the Patellar Tendon? (3)
- High tensile strength and stiffness
- Can obtain rigid graft fixation as have bone on bone healing at graft sites
- Clinical studies indicate good, not excellent, short and long term results
In general, patellar tendon graft bone plugs heal within ___
6 to 8 weeks
What are disadvantages of using Patellar Tendon?
Higher incidence of Patellofemoral Joint pain post-surgery
What are the issue withHamstring (semitendinosus) or Hamstring/Gracilis grafts?
- Biggest issue is graft fixation strength
- Ability of soft tissues to heal in bone tunnels
- Pain with contraction of hamstrings
Soft tissues grafts can take up to ___
12 to 16 weeks
To obtain comparable patellar tendon strength values, the use of Hamstring or Hamstring/Gracilis tendons require
multistrand grafts
What is a multistrand graft?
3 and 4 stranded grafts using braided together
Studies indicate that 4 stranded grafts are stronger and stiffer than
patellar tendon grafts as well as a normal ACL
Most recently use of a double-bundle ACL replacement, initially a ___ allografts were used.
two tibilais anterior
What are requirement for optimal healing?
- Controlled functional stresses to stimulate and direct collagen position during healing.
- Protection from excessive stresses in Phases 2 and 3.
What are 2 major post-operative concerns for physical therapist?
- Prevent graft from being stretched
2. Protection of graft fixation sites
What is the function of the Meniscus? (3)
- Attenuate joint reaction forced by increasing surface area (P=F/A)
- Increase joint congruence, thus increasing joint stability
- Aid the ligaments in stabilizing joint complex
What happens to joint reaction forces from the Meniscus?
decreases approximately 40 to 50%
T/F: The vascular supply is poor to the majority of the meniscus.
True
What is the outer 1/3 termed?
The RED ZONE
Describe the blood supply to the RED ZONE?
has richest blood supply
Where does the RED ZONE get its blood supply
via coronary ligaments
What is the central 1/3 termed
INTERMEDIATE ZONE
Describe the blood supply to the INTERMEDIATE ZONE
has limited blood supply
What is the inner 1/3 termed?
WHITE ZONE
Describe the blood supply to the WHITE ZONE
has no blood supply
What is classic description of injury termed?
Bucket-Handle tear
T/F: Surgical Repair of a meniscal tear is a new concept.
False: Not a new concept, but greater awareness of saving the meniscus today, than in 60’s or 70’s
With what age range are best results obtained for surgical repairs?
under 40 years
What is the ideal length of meniscal tear to suture?
30mm or less
In what zones are suturing most likely to heal?
If tear is in Red or Intermediate zone
What surgical replacement option is there?
Meniscus allograft transplantation
What are the current issues with Meniscal Allograft Transplantation? (4)
- Risk of disease transmission
- Optimal graft preservation methods
- Can allograft reproduce functions of meniscus
- Effect of sizing and fixation methods on contact mechanics
What 4 physical exams can be done for meniscus?
- Joint Line Tenderness
- Bounce Home
- McMurray’s test
- Thessaly test
What 2 tests can be done that have minimal evidence to support?
- Apley’s compression test
2. Ege’s test
