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*Surgery > Knee > Flashcards

Knee Flashcards

1
Q

Patella

A

Largestsesamoid bone,protectstheknee • Fulcrumforquadriceps • Bipartitepatella– usuallyasymptomatic

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2
Q

BipartitePatella

A

Not a fracture! But often confused as one. a congenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones instead of a single bone. Normally, the two bones would fuse together as the child grows but in bipartite patella, they remain as two separate bones

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3
Q

Tibia

A

• Jointcapsule:15mmdistaltojointline • Intercondylar tubercles(spines):ACLattachment • Gerdy’s tubercle:ITbandattachment • Medialplateau(ovalandconcave) • Lateralplateau(circularandconvex) • Lateralmoresensitivetomeniscalinsufficiency • Mostcommonlyfractured

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4
Q

Fibula

A

• Styloid process • LCLandBicepsfemoris insertions • Commonperoneal nerve

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5
Q

ACL– anteriorcruciateligament

A

• Extrasynovial butintra‐capsular • Providesstabilitytoanteriorandrotationalforce • Twobundles– Anteromedial andPosterolateral

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6
Q

PCL– posteriorcruciateligament

A

• Providesstabilitytoposteriorforce • Twobundles– AnterolateralandPosteromedial • Remember“PAL”

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7
Q

Posterolateral Corner

A

• Providesstabilitytorotationalstability • Arcuate ligament,popliteus,posterolateral capsule,LCL,popliteofibular ligament,lateralheadofgastrocnemius

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8
Q

Name the ligaments of the Knee (8)

A

PCL, ACL, MCL, LCL, Medial/Lateral Menisci, Patellar, Transverse Lig of the knee

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9
Q

ACL

A

O: Lat wall of intercondylar notch, I: Ant intercondylar notch, F: Anterior/rotational forces

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10
Q

PCL

A

O: Med wall of intercondylar notch, I: post tibial sulcus, F: posterior force

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11
Q

Deep MCL

A

O: med epicondyle, I: medial meniscus, F: holds MM to femur

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12
Q

Superficial MCL

A

O: medial epicondyle, I: medial tibia, F: resist valgus force

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13
Q

LCL

A

O: lat epicondyle, I: fibular head, F: resist varus force

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14
Q

Intermeniscal

A

O: anterolateral meniscus, I: anteromedial meniscus, F: stabilize menisci

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15
Q

Coronary

A

O: meniscus, I: tibial periphery, F: meniscal attachment

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16
Q

Menisci- Key Points

A

Meniscideepentheconcavityoftibial facets • Outer1/3isvascular(Red‐Redzone) • Inner2/3isavascular(Red‐whiteandwhite‐white) • Medialtears– overallmorecommonbecauseitislessmobile(fixed) • Lateraltears‐ commonwithACLtears

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17
Q

Radiographic Landmarks of the Knee

A

Femur, Tibia, Fibula, Med/Lat condyles (femur and tiba), Tibiofemoral joint, Prox/dist tibiofibular joint, Patellofemoral joint

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18
Q

Articular Cartilage

A

• Linesthejointsurfaces • Lowcoefficientoffriction(0.001; Teflon0.04) • Alymphatic,aneural,avascular • Consistsofwater,chondrocytes, andmatrix

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19
Q

Composition of Cartilage

A

Water– 65‐80%wetweight • IncreasesinOsteoarthritis(OA) • Responsiblefornutrition • Collagen– 10‐20%wetweight • TensileStrength • TypeIIcomprises90% • Othertypes:V,VI,IX,X,andXI • TypeX– hypertrophicchondrocytesduringcartilagegrowth • HighconcentrationinDeerAntlers • Schmidt’sMetaphyseal Chondrodysplasia

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20
Q

Proteoglycans

A

• Compressivestrength • 10‐15%wetweight • ComprisedofGlycosaminoglycans (GAGs) • ChondroitinSulfate • KeratinSulfate • GAGsboundtoproteincoretoformAggrecan molecule • Aggrecan boundtoHyaluronicAcid(HA)toformaggregate

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21
Q

Chondrocytes

A

• 5%ofwetweight • Producesthematrixcomponents • “Highlyspecialized” • Respondtomechanicalloads,solublemediators • Metabolismslowswithage

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22
Q

CartilageHealing

A

• Deepinjuryleadstoinfluxofmesenchymal stem cellsandfibrocartilageproduction • Superficialinjurydoesnotheal

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23
Q

Knee Exam

A

HIPROT

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24
Q

History

A

• Onset • Location • Severity • Aggravatingfactors • Nature • Mechanicalsymptoms • Treatments

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25
Q

Inspection

A

• Generalalignment • Scars • Effusion

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26
Q

Palpation

A

Tendernesstopalpation • Jointlines • Mostaccurateformeniscaltear • Patellartendon • Quadricepstendon • Pes anserinebursa • Fibularhead • Popliteal space • Gerdy’s tubercle

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27
Q

RangeofMotion

A

• Usegoniometer • Locateaxesoffemurandtibia • Normalkneehyperextends

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28
Q

StabilityExams

A

Lachman, Ant/Post Drawer, Pivot Shift, External Rotation‐Recurvatum, Valgus and Varus Stress, TEST THE GAIT

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29
Q

Lachman’s Test

A

• Flexto30degrees • Comparetocontralateral side • Grade0– nodifference • Grade1– 1‐5mmdifference • Grade2– 5‐10mmdifference • Grade3‐ >10mmdifference • Feelforendpoint • ConfirmwithKT‐1000 • MostaccuratetestforACLtear; A- good endpoint, B- no solid end point

30
Q

Anterior/PosteriorDrawer

A
  • Flexto90degrees • • Grade 0 – Normal
  • Grade 1 – Normal step‐off
  • Grade 2 – Flush with tibial plateau
  • Grade 3 – Sags posterior to plateau
31
Q

PivotShift

A

• Mostdifficulttoperfect • Startextended,internallyrotate,axial load,thenflexslowly • Willfeela“clunk”ifpositive • DiagnosticforACLdisruption

32
Q

Valgus andVarus Stress

A

• Performedat0and30degreesofflexion • Reasonablyaccuratefordiagnosisofcollateralligamentinjury

33
Q

McMurray’stest

A

• Meniscal test • Fullyflex,internally(orexternallyrotate) thenextendslowly • Painand/orclick

34
Q

Apley’s test

A

he examiner then places his or her own knee across the posterior aspect of the patient’s thigh. The tibia is then compressed onto the knee joint while being externally rotated. If this maneuver produces pain, this constitutes a “positive Apley test” and damage to the meniscus is likely.

35
Q

Thessalytest

A

Standonaffectedflexedleg,twist

36
Q

PatellaExam

A

• Tendernesstopalpation • CompressionPain • Apprehension • Crepitation • Translation • J‐sign • Q‐angle

37
Q

WhentoOrderX‐rays (Knee)

A 
Ottawa knee rules (• Age >55
• Tenderness at head of fibula
• Isolated tenderness at patella
• Inability to flex knee 90 degrees
• Inability to bear weight four steps immediately and in examination room), hemarthrosis, Not used routinely
38
Q

What Knee X-rays to Order

A

Weight bearing PA 10* flexed MTP, lateral flexed 30*, Merchant (patellar view)

39
Q

Why use a MTP view over a standing extended AP?

A

MTPviewprovidesmoreaccurateandmore reproduciblemeasurementofJSWthanSEV.

40
Q

WhentoOrderMRI

A

• Replacesthe“diagnosticarthroscopy” • Accurateforligamentandmeniscaltears • Ruleofthumb:“Whatwillwedowiththis information?” • ManyinjuriescanbeassessedwithoutMRI, butMRIisusefulfordiagnosis.

41
Q

PatellaDislocation

A

7per100,000peryear • Adolescents:43per100,000peryear; Risks • Female • FamilyHistory • PriorHistory • DegreeofTrauma(recurrent)

42
Q

SoftTissueAnatomy (patella)

A

• Patellatendon • Patellofemoralligaments • Patellotibial ligaments • Patellomeniscal ligaments?

43
Q

MPFL

A

• Primarystabilizertolateraldisplacement • 50‐60%ofmedialrestrainingforce • First20‐30degreesofflexion • MoreinVMOdysplasia • Dynamized byVMO

44
Q

NonOperativeTreatment of Patellar Dislocation

A

• Initialdislocation • Redislocation:15‐44% • Symptoms:50% • Corestrengtheningrehab • VMOstrengthening • Orthoses

45
Q

IndicationsforMPFLReconstruction

A

Anypatientwithtwodocumentedpatellardislocationsandexam findingsofexcessivelateralpatellarmobility

46
Q

MeniscusTear

A

disruption of meniscal integrity; Mechanism
• Twist, “stepped wrong”, antecedent minor injury
Clinical Diagnosis
• Joint line tenderness, McMurray test
• MRI to evaluate character of tear

47
Q

Tx of Meniscal Tear

A

• Non‐operative • Surgicalmeniscectomy • Arthroscopicrepair

48
Q

Long‐termOutcomes- Meniscal Tears

A

• 50%developradiographicchangesofarthritisin10‐20 years. •Worseinwomen,obese,andlateralmeniscus • Subsetsexist • Traumatictear • Degenerativetear

49
Q

ACL Reconstruction

A

• Surgerydecreases“givingwayepisodes,meniscustears,andarticular cartilageinjuries. • 15‐20%haveresidualpainpost‐operatively • 40‐50%haveradiographicchangesofarthritisat10yrs postoperatively • Manyhavepersistentpivot‐shiftwithsingle‐bundlereconstruction

50
Q

ACL Rehab

A

Return to sports: 4-6 months (sport and patient dependent); Regular visits up to 1 yr post-op; • Hinged knee brace locked in extension
• FWB in full extension
• CPM 0‐30°, increase by 10° per day for one week
• Brace unlocked at one week
• Crutches used until quadriceps control in achieved
• Return to sports at 6 months

51
Q

ACLtear

A

•DisruptionofintegrityofACL • Twistonaplantedfoot,fallfrom height •Clinicaldiagnosis • Effusion,Lachman,Pivotshift • MRItoassesscartilage,bone, meniscus • Treatmentvariable

52
Q

ACLAnatomy

A

•Intra‐articular,extra‐ synovial • Twoseparatebundles • Anteriomedial • Posterolateral •Distinctbiomechanical functions

53
Q

ACL Biomechanics

A

Extension: • AMloosens • PLtightens; Flexion: • AMtightens • PLloosens

54
Q

Knee Dislocation

A

• Highenergymulti‐ligamentouskneeinjury • Riskofassociatedinjuries • Commonperonealnerveinjury(25%,50%partiallyrecover) • Vascularinjury • Poplitealarterytetheredproximallyanddistally • Neurovascularexaminationimportant • IfABI>0.9,thenserialobservation • IfABI

55
Q

Osteoarthritis

A

• 27millionaffectedintheUnitedStates. • Thirdleadingcauseofyearslivingwithadisability(YLD)inthe UnitedStates • 600,000+totaljointreplacementsperformedperyear • 50%ofpeopledevelopOA10yearsaftermajorjointinjury

56
Q

Non‐operativeManagement of Osteoarthritis

A

1) Educatepatients 2) Regularcontact 3) BMI>25shouldlose5%BW 4) Lowimpactaerobics 5) Maintainflexibility 6) Quadstrengthening 7) Patellar taping for short term relief
8) Lateral heel wedges don’t work
9) Unable to make statements about …
• valgus‐producing bracing
• varus‐producing bracing
• or accupuncture . 10) Don’t prescribe glucosamine and chondroitin
11) Use NSAIDS and/or Acetaminophen
12) Use Acet, topical NSAIDS, or COX‐2 inhibitors
with GI problems
13) Steroid injections for short‐term relief 14) Cannot recommend hyaluronate products
15) Don’t use needle lavage
16) Don’t use arthroscopy for primary diagnosis
of DJD
17) Meniscectomy or loose body removal is “an
option”

57
Q

HistoryandPhysicalExam

A

•Acuteosteochondralinjury •Osteochondritis Dissecans •Chronicdegenerativelesion •ROM,alignment,effusion, stability •Radiographsshowlossofjoint space,subchondral cystsor sclerosis,andosteophyte formation

58
Q

Outerbridge Classification of Cartilagenous Injury

A

• Grade0:Normalcartilage • GradeI:Softeningandswelling • GradeII:Superficialfissures • GradeIII:Deepfissures,withoutexposedbone • GradeIV:Exposedsubchondralbone

59
Q

CartilageRepairTechniques

A

Marrow Stimulation, Autologous Plug Transplantation, Autologous Chondrocyte Implantation, Osteochondral Allograft Transplantation, Knee arthroplasty

60
Q

Marrow Stimulation

A

• Microfracture • Allowmesenchymalstemcellsaccessto defect. • CPM6hoursperdayfor6weeks • Non‐weightbearingfor6weeks. • Resultshighlydependentonthesizeof thedefect • Especiallylargerthan2X2cm

61
Q

Autologous Plug Transplantation

A

• OATSormosaicplasty • Replacecartilagedefectwithplug fromrelativelylowerweightbearing segment • Weightbearingdelayed3months. • Limitedbydonorsizeanddonorsite morbidity.

62
Q

Autologous Chondrocyte Implantation

A

– Carticel orothers • Celltherapyforming “hyalinelike”cartilage • Limitedbycost,two surgeries,outcomes similartomicrofracture

63
Q

OsteochondralAllograft Transplantation

A

• Transplantationoflivecartilage • Canaddresslargedefects • Lowriskofinfection,limited availability,cost

64
Q

TotalKneeArthroplasty

A

• Performedthroughmedial parapatellar approach • Goalistorestorealignmentand achieveROM • Balancekneeisflexionand extension • Gapsshouldbeequal

65
Q

PatellaFracture

A
  • Causedbydirectimpacttothe anterioraspectoftheknee • Canbeassociatedwithotherinjuriesfromdashboardmechanism Evaluation
  • Inability to perform straight leg raise indicates extensor mechanism disruption
66
Q

Tx of Patellar Fracture

A

• Non‐operativeifnon‐displaced • ORIFwithtensionbandconstruct

67
Q

DistalFemurFractures

A

Highenergyinjuryinyounger populationorlowenergyinjuryinolder patients • Evaluation:radiographs,CTto determineextentofintra‐articular involvement

68
Q

Tx of Distal Femur Fracture

A

• Non‐operativeinnon‐displaced • Externalfixationfortemporarytreatment • ORIFtorestorenormalanatomy • Intramedullarynailforsupracondylar fracture • Distalfemoralreplacementforsomewith priortotalkneereplacement

69
Q

Tibial PlateauFractures

A

• Periarticularfracturevarus orvalgusload • Associatedinjuries • Meniscaltear,ACLtear,compartmentsyndrome,vascularinjury • Radiographs,CT,considerMRIpriortosurgicaltreatment

70
Q

Tx of Tibial Plateau Fractures

A

• Non‐operativeifnon‐displaced • Externalfixationfortemporaryorsevereopeninjury • ORIFforarticularstepoff ordisplacedfractures

71
Q

Schatzker Classification

A

Type I- split, Type II- split depression, Type III- central depression, Type IV- split fracture medial plateau, Type V- bicondylar fracture, Type VI- dissociation of metaphysis and diaphysis

72
Q

ORIF on Tibeal Plateau Fractures

A

• Approachdependsonfracturetype • Reductionandfillthemetaphyseal bonevoid/defectwithbonegraft • Internalfixationwithlockplate/plates

*Surgery (9 decks)

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