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6 Orthopedics > L12 LE Surgeries > Flashcards

L12 LE Surgeries Flashcards

1
Q

Proximal Hamstring Tears

A

-30% of new LE injuries in atheltes
-common in soccer, track, field, football
-eccentric contraction of hamstring when muscles are at max elongation

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2
Q

Avulsion hamstring injury

A

sudden hip flexion/kne extension

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3
Q

Sudden takeout phase of running causes

A

intramuscular or musculotendinous injuries

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4
Q

Conjoint tendon

A

semitendinosus and long head biceps

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5
Q

Presentation of Proximal Hamstring Tears

A

-pop followed by sudden pain in post thigh and buttock
-painful to sit
-palpable painful mass, palpable defect
-everyone will be weak initially, regardless of grade
-sciatic irritation not common in acute

bruising indicates higher grade injury

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6
Q

Exam/imaging for proximal hamstring tears

A

-x ray always, looking for bony avulsion in younger patients
-MRI to determine if surgical in appropriate patient

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7
Q

Treatment for proximal hamstring tears

A

nonoperative in most situations
Rest, NSAIDs, PWB for 4 weeks, PT
usually 3 month recovery

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8
Q

Who has non-operative proximal hamstring tears?

A

single tendon tears
2 tendon tears <2 cm retraction
myotendinous jxn injury
low demand/poor surgical candidates

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9
Q

Surgical Treatment for Proximal Hamstring Tears

A

acute within 4 weeks
repair with 2-4 anchors in ischial tub
open or endoscopic
+/- sciatic neurolysis

chronic requires reconstruction w/bridge graft

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10
Q

Outcomes for proximal hamstring tear surgeries

A

84% return to pre-injury strength
8% sciatic n injury
12% re-rupture rate

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11
Q

Grade 0 Ligament Laxity

A

<2 mm translation
tight, firm endpoint, same as contralateral side

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12
Q

Grade 1 Ligament Laxity

A

3-5 mm translation
normal increase compared to contralateral side

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13
Q

Grade 2 Ligament Laxity

A

6-9 mm translation
slight increase in laxity, soft endpoint

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14
Q

Grade 3 Ligament Laxity

A

> 10 mm, significant laxity and no endpoint

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15
Q

ACL Injury

A

knee valgus collapse and hip adduction

poor landing mechanics, neuromuscular activation

usually non-contact, with tibia translating anterior with knee flexed in valgus

contact injury = direct blow to lateral knee

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16
Q

History/Exam of ACL Injury

A

-felt a pop, pain, swelling, unable to WB
-rapid effusion, limited mobility
-exam often confounded by guarding/swelling
-pivot shift in acute isn’t helpful
-should still consider ACL even if exam isn’t clear, but history is

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17
Q

Imaging ACL Injury

A

X ray = can show segond fracture
MRI = confirms tears, looks for other pathology like L. meniscus, chondral damage, collaterals

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18
Q

Treatment of ACL

A

consider patient, activity level, expectations. is it a functional instability or sports instability

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19
Q

Nonoperative treatment for ACL

A

use PT and functional bracing
low demand patients
recreational activities not in level 1 or 2
arthritis

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20
Q

Sports Activity Rating

A

1 = jumping, cutting, pivot
2 = lateral movements, less pivot
3 = straight ahead actions
4 = sedentary

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21
Q

Repair for ACL

A

Partial tears, proximal tears, avulsion
internal brace is really helpful
reconstruction is the gold standard

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22
Q

Bridge Enhanced ACL Repair

A

new in last 2-3 years
comparable to ACLR

acl repaired with collagen based implant soaked in PRP, helps bridge the gap and heal the ACL

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23
Q

ACL reconstruction

A

gold standard
prehab is critical, need full ROM and no swelling

3 months post injury is the best time
Post-op rehab is key in patients looking to return to sport

post rehab should be at least 6 mo

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24
Q

For active high level athlete

A

bio ACL with quads tendon autograft

lateral extra-articular tenodesis, helps to reduce reoccurrence

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25
Q

Low demand/functional instability patients

A

soft tissue allograft

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26
Q

Moved away from bone/patella

A

quad outcomes equal
less morbidity

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27
Q

MCL Injury

A

most common ligamentous injury
valgus stress w/knee in flex and ER
proximal tears more common
often associated with ACL tear

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28
Q

Distal MCL Tear…

A

has poor healing capacity

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29
Q

Superficial MCL

A

primary valgus restraint at all angles, greatest in 30° flexionD

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30
Q

Deep MCL

A

secondary stabilizer, greatest in full extension

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31
Q

Presentation of MCL injury

A

valgus stress, medial pain, maybe swelling

instability with WB

laxity w/valgus stress, increased laxity in full ext

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32
Q

Treatment for MCL injury

A

almost always non-operative
grade 1 = nsaids, rest, RTP 1-2 weeks
grade 2 = bracing, RTP 4-6 weeks
grade 3 = bracing 4 wks, RTP 8-12

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33
Q

MCL is operative…

A

chronic laxity (grade 3)
full distal tears or flipped proximal
multigamentous injuries

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34
Q

When to use repair for MCL

A

acute grade 3 w/multi ligament
displaced distal avulsion
entrapped in joint

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35
Q

When to use reconstruction with allograft

A

chronic injury
loss of good tissue
gold standard in most cases

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36
Q

PCL Injury

A

always traumatic
fall with knee in HE, foot PF
presents with posterior instability
often associated with PLC

37
Q

Exam for PCL

A

posterior sag sign
posterior drawer (most accurate)
dial test (for PLC)

38
Q

Non-operative treatment for PCL

A

isolated tears
bracing, protected WB, rehab

39
Q

Operative PCL injury

A

isolated grade 3 in young athletes
multigamentout injuries
displaced avulsion fx
chronic instability

40
Q

PCL Repairs

A

for acute and avulsion injuries

41
Q

PCL Reconstruction

A

chronic, significant tissue loss

42
Q

LCL injury

A

sudden varus force to knee
isolated is very rare, often with PLC

LCL is tight in extension, lax in flexion

43
Q

LCL Injury Symptoms/Exam

A

instability near full ext
difficulty with stairs
lateral pain/swelling
tender over LCL
hyperextension/varus thrust

44
Q

Nonoperative treatment for LCL

A

isolated grade 1 or 2
bracing, progressive ROM, functional rehab
RTP by 6-8 weeks

45
Q

Operative LCL Treatment

A

Need to prove that you need it
treat all isolated with non-op
reconstruct who needs it
fix/repair displaced avulsion fx
reconstruct LCL/PLC injuries
rate of failure is very high

46
Q

Meniscal Tears

A

traumatic or degenerative

most common indication for knee surgery

higher risk in ACL tears b/c they become stabilizers

medial more common that lateral except with ACL injuries

47
Q

Tear Types for Meniscal Tears

A

vertical/longitudinal
bucket handle
oblique/flap/parrot
radial
horizontal
complex
root

48
Q

Vertical/longitudinal

A

common with ACL tears

49
Q

Bucket handle

A

progression of vertical tear
locked knee

50
Q

Oblique/flap/parrot beak

A

often cause mechanical symptoms

51
Q

Radial

A

full thickness tears
rapid arthritis

52
Q

Horizontal

A

common in older population
associated with meniscal cysts

53
Q

Complex

A

usually chronic, degernative

54
Q

Root

A

functionally equivalent to total meniscectomy

55
Q

Presentation of Meniscal Tears

A

-twisting, immediate focal pain
-delayed effusion
-pain S/S with pivoting, deep flexion, squat
-possible effusion
-joint line tenderness
-pain with high flexion

56
Q

Non-operative for meniscal tears

A

first line for degenerative tears
outcomes equivocal to menisectomy
stable apearing tears in red zone
NSAIDs, PT
do NOT use PRP

57
Q

Surgery for Meniscal Tears

A

unstable tears, mechanical S/S
acute tears in young pts
root tear
buckethandle tear

58
Q

Meniscal Root Tears

A

middle aged, overweight
pop in posterior knee
severe pain, swelling, instability

aggressive surgical indications, conservative tx will not heal this

59
Q

Meniscus allograft transplant

A

young, healthy patient with subtotal meniscectomy

no or minimal degenerative changes

address concomitant pathology like ACL, cartilage, malalignment

60
Q

Articular Cartilage

A

made mostly of water and type 2 collagen, proteogylcans, chondrocytes

helps to decrease friction and distribute load

61
Q

Fibrocartilage

A

located in menisci, and is made of fibrous cartilage, type 1 collagen, some proteoglycans, chondrocytes

healing response to injury of articular cartilage. Compressive strength

62
Q

Osteochondritis Dessicans

A

pathologic lesoin affecting articular cartilage and subchondral bone

present in juvenile or adult, most common in the knee

can be heriditary, traumatic, vascular

63
Q

Pathoanatomic cascade of OCD

A
  1. softening of overlying articular cartilage
  2. early articular cartilage separation
  3. partial detachment of lesion
  4. osteochondral separation with loose bodies
64
Q

Symptoms of OCD

A

activity related pain, vague, poorly localized

mechanical symptoms–unstable lesion, advanced disease

recurrent knee effusions

use MRI to diagnose advanced disease

65
Q

MRI characterizes these things for OCD

A

size
status of bone
stability of lesion
loose bodies

66
Q

OCD Staging

A

1 = small area, compression on subchondral bone
2 = partially detached fragment
3 = fully detached, still in crater
4 = complete detachment/loose body

67
Q

Nonoperative Tx for OCD

A

stable lesions, open physes
asymptomatic lesions in adults
restricted WB with bracing up to 3 mo
50-75% will heal

68
Q

Operative Tx for OCD

A

unstable lesions, impending physeal closure, expanding lesions on XR, failed non-op

options include subchondral drilling, fixation of lesion >2 cm, chondral resurfacing, arthroplasty

69
Q

Prognosis for OCD

A

correlates with age, location, appearance

open physes is best predictor of successful nonoperative tx

medial femoral condyle is better

adult OCD, sclerosis on x rays and fluid behind lesion on MRI is worse

70
Q

Osteochondral Grafting–OATS

A

patient <50 yo, BMI <35, with lesions up to 15 mm

transfer of healthy cartilage from NWB area to the lesion

71
Q

Osteochondral Grafting–OCA Transfer

A

for large lesions too large for autograft
fresh sterilized cadaver that is pt match

not useful in OA, bipolar lesion, inflammatory arthropathy, >50 years, smoking/alcohol abuse

72
Q

Chondromalacia

A

sick cartilage, most often seen on patella and causes ant knee pain

most common in adolescents, young adults, women

73
Q

Etiology of chondromalacia

A

roughening/damage to patellar cartilage

mult-factorial: muscle weakness, anatomy, patellar maltracking. Basically elevated PF contract pressures

miserable malalignment syndrome

74
Q

Miserable malalignmnet syndrome

A

femoral anteversion, genu valgum, external tibial torsion, increased Q angle

75
Q

Presentation of chondromalacia

A

retropatellar pain, often radiates post
insidious, chronic, vague
pain w/stairs, prolonged sitting, squat

quad atrophy, positive J sign, lateral patellar sublux, crepitus, pain with patellar compression with ROM

76
Q

Chrondomalacia Imaging

A

X-ray = shallow sulcus, patellar tilt

MRI = assess cartilage, trochlear dysplasia, patellar tracking, rotation

77
Q

Nonoperative Tx for Chondromalacia

A

almost always first line tx

min 6 mo before considering surgical intervention

avoid steroids

rehab focusing on core, posterior chain, hip ER, closed chain quad, flexibility

78
Q

Operative Treatment for Chondromalacia

A

cartilage = chondroplasty, microfx

alignment = lateral elngthening, patellar realignment

trochlear deepening

79
Q

MACI

A

for full thickness chondral defects up to 8 cm

patient harvested chondrocytes cultured and grown on film

implanted back into defect

excellent outcomes in appropriate patients

80
Q

Realignment for chondromalacia

A

tibial tubercle osteotomy for patellar instability

increasingly more popular for chondromalacia

idea is to offload diseased area, improve tracking

81
Q

Knee Arthritis

A

degenerative process causing progressive loss of articular cartilage

pain at rest, activity induced swelling, stiffness, instability, mechanical

82
Q

Anyone above a grade ____ needs knee replacement

A

3

83
Q

Grades for arthritis

A

Grade 0 = no OA
Grade 1 = minute osteophyste
Grade 2 = definite osteophyte, normal joint space
Grade 3 = some joint space reduction
Grade 4 = joint space greatly reduced

84
Q

Nonoperative Treatment for OA

A

rehab, education, wellness
NSAIDs
weight loss program
bracing

85
Q

Controversial treatments for OA

A

viscosupplementation (works with 60%)

corticosteroid injections (doesn’t work with activity based pain)

orthobiologics like PRP

86
Q

Operative treatment for OA

A

High tibial osteotomy
Unincomportmental arthroplasty
Total knee arthroplasty

87
Q

High Tibial Osteotomy

A

young, active, healthy patients
isolated OA with varus malalignment
many contraindications

88
Q

Unicompartmental arthroplasty

A

older, low demand, health pts
unicompartmental disease
many contraindications

has faster rehab, less morbid, preservation of normal kinematics. Has high loosening rate and stress fx

not many patients meet the criteria

89
Q

Total Knee arthroplasty

A

most people do great

15-20% of people have pain with no physiologic explanation

survival rates of at least 80% at 20 years

arthroscopic debridement is not recommended. Could make it worse and 50/50 chance success

6 Orthopedics (17 decks)

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