Knee patho (PF and ottawa)- Dr. Davies Flashcards
Ottawa Knee Rules (what is the point)
why do you need a radiograph
a negative result on an Ottawa Knee Rule test accurately excluded knee fx after an acute knee injury
acute knee injury- only about 7% have fracture
Ottawa Knee Rules (details on the studies)
N=4249
Sen= 98.5%, Spec= 48.5%
*quite a bit of research on this starting back in 1995, done on thousands of patients
*the final one was a systematic review on the guidelines, when to use and when not to use a radiograph
Ottawa Knee Rule (type of knee injuries)
most knee injuries results from a direct blow, fall, or twisting injury
Blows and falls are referred to as a macrotrauma or “blunt injury” and account for 25% of knee injuries (80% of all fractures)
finding a fracture in a blunt injury versus a twisting injury
finding a fracture is 4 times more likely after a blunt injury than after a twisting injury
Ottawa Knee Rule (5 yes or no)
1) age 55 years or older
2) isolated tenderness of patella (no bone tenderness of knee other than patella)
3) tenderness at head of fibula
4) inability to flex knee past 90*
5) inability to bear weight both immediately and in an ER for 4 steps (unable to transfer weight twice onto each lower limb regardless of limping)
why do you need a radiograph in adults over the age of 55?
osteoporosis, etc occurs more in older adults
tenderness on the patella (Ottawa Knee Rules)
usually secondary to landing on the patella if they fall or if something hit them directly; direct marcotrauma
tenderness over the head of the fibula (Ottawa Knee Rules)
occurs when there is a direct macrotraumic injury to the head of the fibula
which Ottawa Knee Rule does Dr. Davies not agree with
not being able to bend the knee past 90*
there are a lot other injuries (ACL, PCL, meniscus, etc) that can cause the knees to not want to bend past 90 (from a twisting injury)
Ottawa Knee Rules (practical application)
patient’s preference and point of view might influence the use of the Ottawa Knee Rules in clinical practice
what are the first two parts of the body parts to “go”
the low back is first to “go” then the knees
Patellar Femeral Pain Syndrome (other names)
(PFPS) (AKPS) anterior knee pain syndrome the black box of orthopedics the mysterious syndrome *so many different possibilities, yet the most common in the knee*
How to grade the patella
grade on a quadrant system
the patella is sitting in the center of the femoral sulcus; will push the patella out of the sulcus and grade the subluxation; grade 2 is normal
(grade 1 is hypo, grade 3 is hyper)
*testing the superficial fibers of the retinaculum
measuring a tilt of the patella
measuring the deep fibers of the retinaculum
a line through the medial and lateral epicondyles; will tilt the patella; the tilt is defined as the direction towards the femur (so the medial tilt will test the lateral deep fibers)
15* is normal
how to treat PFPS
the key to treating patients with PFPS is to treat the CAUSE and not just the SYMPTOMS
Sun Rise View
the x ray beam is at different angles to see the patella in the femoral trochlea (there are different types of views that are dictated by the doctor, Skyline view, etc)
which is higher: lateral or medial femoral condyle in relation to the patella
the lateral side should always be higher, it should acts as a boney buttress
Lateral Trochlear Dysplasia
when the lateral trochlea is the same high as the media
measurements on the sunrise view
TT: tibial tuberosity
TG: trochlear groove
Q angle
where you measure from the ASIS to the mid patella to the tibial tuberosity
it measures the pull of quadriceps at the knee
~valgus vector- 5-10 for males, 10-15 for females
Patella Alta
(grasshopper eyes)
found by the Insall-Salvati Ratio on a lateral radiograph; patient is standing and measure the tibial tuberosity to the inferior pole of the patella and inferior to the superior pole of patella; should be 1:1 ratio (.2 is the standard deviation)
unstable patella
Squinting Patellas
can be with Patella Alta or Baja;
patellas are inward
Patella Infera (Baja)
smaller Install-Salavati Ratio
more OA changes
Fabella
boney growth in the lateral head of the gastro
Bayonet Sign (knee)
squinting knee that has the proximal external tibal deformity; makes the leg look like a bayonet
genu varum
Camel Sign (knee)
two humps when looking at the lateral view of the knee
patella is one hump and the second hump is the intrapatella fat pads
Miserable Malalignment Syndrome
1) Femoral anteversion
2) Squinting patellas
3) Proximal tibial torsion
4) Distal tibial verum
5) STJ pronation
PF biomechanics
lateral vector- VMO and medial rect in the medial diction; lateral rect, IT band, and vactus lateralis
*want the patella to go in a straight line or in a straight line with a slight medial in the center and back to the center
Chondromalacia
DONT USE IT unless the doctor has it documented on a surgical note
Classification of Patella Dislocation (2)
LAACS and TONES
*know that Fulkerson is the person that wrote the article
LAACS
L: laxity, generalized and lower- aged at initial dislocation
A: atraumatic in nature
A: abnormal patella femoral architecture and abnormal ligamentous laxity
C: chronic in nature; contra lateral involvement
S: sex dependent with greater number of females
TONES
T: traumatic, sports related MOI
O: older at initial dislocation, OCD fracture more common
N: normal PF architecture, normal alignment
E: equal sex distribution
S: single occurrence, single leg involvement
PF Classifications
Patellar compression syndrome Patellar instability Biomechanical dysfunction Direct patellar trauma Soft tissue lesion Overuse syndrome Osteochondritis disease Neurological disorder *Hoffa's Syndrome
Hoffa’s Syndrome
pain in the infrapatellar fat pad
Dye’s research
he scoped his knee without anesthesia to rate the pain in different parts of the knee
2 parts of the research: pain and general/ localized
worst pain was in the infrapatellar fat pad
Other terms for Surgical Shortening
Plication Imbrication Reefing "Vest Over Pants" Capsulorraphy
Proximal Realignments
Lateral Release
VMO Advancement/ Reefing
MPFL-R
Lateral Release
about
done when the lateral side it too tight or the medial side is too loose
Usually the tight lateral retinaculum
Lateral Release
surgery
go in and cut the lateral retinaculum up to the VL
will allow the patella to be correctly aligned from the lateral tilt and/or glide into the sulcus
*want the scarring to occur in the stretched position
Lateral Release
Complication
when there is a lateral release, a complication is cutting the superior lateral genicular artery, which leads to a lot of effusion
*try and cauterize it to minimize the bleeding, but it still seems to bleed a lot during this surgery
Why do they do a VMO Advancement?
since they just loosen the lateral side with a lateral release, it would make sense to tighten the medial side
VMO Advancement
what is it
Shorten the medial side because it was all stretched out
put the patella back in the correct location and then tighten the VMO to keep the patella in the correct alignment
MPFL (what does it stand for)
Medial Patella Femoral Ligament
MPFL (what does it do)
this is the primary stabilizer for the patella
MPFL (surgery)
gracilis tendon (auto graft) or allograft
can drill all the way to the other side or make a “V” or put suture anchors into it
do something to tighten it
*this is the number one *surgery for PF stabilization now
a fully torn will need surgery
Distal Realignment Procedures
Hauser
Elmslie Trillat
Fulkerson’s Anteromedialization
Maquet
MPFL-R
medial patella femoral ligament- reconstruction
Hauser Procedure
an older procedure (don’t even worry about it, isn’t used any more); created more problems then helped
Elmslie Trillat Procedure
moves the tibial tuberosity medial;
take the tibial tuberosity and osteotomize (cut it off) and slide it medially
wont see many of these any more
Fulkerson’s Anteromedalization
only moves the tibial tuberosity medial a little bit
*don’t take it as far medially or distally; wont let it go too far medially
sometimes do this with the proximal realignment procedures
Marquet Procedure
elevates the tibial tuberosity
try to minimize the pressure in the PF joint (PF joint reaction forces)
put a bone plug in there to elevate and decrease the pressure
Elmslie Trillat Procedure (Problems)
Problem- it ended up more on the side then in the center
if you take too far medially/ distally, you can create a patella Baja; it was counter productive
Trochleoplasty
(not commonly done in the US; more done over in Europe)
they carve out the femoral trochlea so that the patella will track better
Other Rehab for PF
taping, bracing, VMO activation,
MPFL rehab Protocols
two different: 1) 0-90 in one day or 2) progressive increase in ROM weekly week 1: 0 week 2: 0-30 week 3: 0-45 week 4: 0- 60 week 5: 0-75 week 6: 0-90 *depends on the doc
Biomechanical Considerations in Patellofemoral Joint Rehabilitation (how the graph is set up)
the patellofemoral joint reaction forces
ROM on the x axis: 0 is full extension
pressure per unit contact of the patella in the sulcus is the y-axis
*solid circles is full closed kinetic chain motions (squat)
*open circles is open kinetic chain
Biomechanical Considerations in Patellofemoral Joint Rehabilitation (what the graph means)
when in CKC- extension has very little stress on the knee and starts to increase as the
when in OKC- start at 0* and the pressure decreases as it gets to 90* (pressure is higher per contact surface at 0* than near 90*)
Biomechanical Considerations in Patellofemoral Joint Rehabilitation (how to apply this in the clinic)
you have a patient with PF pain.
have the patient doing squats (CKC) from 0-45* and doing OKC from 90-45* because there is less pain
if there is even more pain in a patient- CKC from 0-30* and OKC from 90-60*
(these are short arc, which have a 20* overflow)
*will be on the exam
