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Semester 2 PM Exam 8 > Surgical Knee Disorders > Flashcards

Surgical Knee Disorders Flashcards

1
Q

Areas that will refer pain to the knee

A

Hip
Back
Leg

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2
Q

Patellofemoral Disorders (2)

A

Patellofemoral Pain Syndrome

Patellar Instability

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3
Q

Patellofemoral Pain Syndrome

A

Patellar malalignment

Patellar compression syndrome

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4
Q

Patellar instability

A

recurrent subluxations and/or dislocations

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5
Q

With patellofemoral pain syndrome what might someone have in subjective/objective findings

A 
Injury history
Overuse injury
Swelling
Clicking, popping, catching
Giving way
NO patellar dislocation history
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6
Q

Patellar malalignment

A

just pain not instability
most commonly is an anatomical malalignment risk factor
Excessive lateral traction
No subluxation hx

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7
Q

Hx with patellar malalignment

A 
Subpatellar/peripatellar pain
Pain w/ stair climbing/descent 
Movie sign
Pain with running
Giving Way
Locking, popping, clicking
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8
Q

Patellar Malignment - Physical Exam

A

Genu valgum
Inc femoral anteversion
Medial facet tenderness
Inc Q (more than 20 F, more than 15 M)

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9
Q

Patellar Compression Syndrome

A

Similar symptoms to patellar malaligment, but alignment is normal
VMO weakness
Tight lateral retinaculum - shortened and thick lateral retinaculum
Lateral release indicated

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10
Q

Recurrent Patellar Instability

A

+ patellar apprehension sign
Osteochondal fractures
A lot of them have dislocated

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11
Q

Mechanism - Recurrent Patellar Instability

A

Direct blow

Indirect - patellar malalignment

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12
Q

Patellofemoral disorders - nonoperative treatment

A 
PT
Activity modification
NSAIDs
Ice
Patellar bracing
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13
Q

Patellofemoral disorders - surgical indication

A

failure to respond to non-operative Rx after 6 months

Persistent pain with ADLs

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14
Q

Patellofemoral Disorders - Operative treatment

A 
Arthroscopy - chondroplasty 
Lateral release
Proximal realignment 
Distal realignment 
Combinations
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15
Q

Surgical treatment for patellar compression syndrome

A

Lateral release

Open v. arthroscopic

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16
Q

Proximal realignment

A

Medial retinaculum repair, plication, VMO advancement
Lateral release
Skeletally immature
Patellar instability

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17
Q

Distal Realignment

A

Tibial tubercle anteromedialization osteotomy
Dec Q angle
Anteriorization dec patellofemoral contact stresses
Need to be skeletally mature

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18
Q

Combined reconstructions for patellofemoral disorders

A

Proximal and distal realignments

Medial restrains loose and inc Q angle

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19
Q

Patellar Instability - First Patella Dislocation tx and risk for recurrent instability

A

initial tx is non-operative unless an osteochondral fracture occurs that can be repaired or removed
Risk for recurrent instability 15-44%

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20
Q

Patella Instability - Recurrent Patella disloaction TX

A

Offer MPFL reconstruction for skeletally mature

Add distal realignment if TT - TG bigger than 20 mm

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21
Q

Plica syndrome

A

Synovitis - trauma or overuse
Crepitation
Clicking and popping
Pseudolocking

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22
Q

Where is the pain with plica syndrome

A

Superior
Anteromedial
Infrapatellar

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23
Q

Tx for plica syndrome

A

Similar to PFPS
Corticosteroid injections
Arthroscopic excision

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24
Q

IT Band syndrome - common in

A

Runners and cyclists

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25
IT band syndrome - what happens
ITB rubs over lateral femoral epicondyle
26
IT Band Syndrome - Treatment
``` Activity modification Stretching - ITB, quads, hams Ice, NSAIDs Corticosteroid injections Valgus producing orthotics Surgery is rare ```
27
Prepatellar bursitis - mechanism
Trauma related | Acute or repetitive
28
Prepatellar bursitis - common in
wrestling
29
Prepatellar bursitis - what is it
inflammation of prepatellar bursa
30
Treatment for prepatellar bursitis
Compression, ice, immobilization/padding NSAIDs Aspiration and cortisone injection Surgery - bursa excision is rare
31
Patellar tendonitis
Jumpers knee Pediatric - sinding larsen johansson Overuse injury patellar tendon Degenerative tendon distal pole patella
32
Patellar tendonitis - tenderness over
patellar tendon, distal pole patella | Chronic pain
33
Treatment for patellar tendonitis
``` Activity motification, ice, NSAIDs Chopat brace Stretching of quads and hams Progressive pain free strengthening Surgery is rare ```
34
Patellar tendon rupture - more common in
younger patients 20-40 years old
35
Patellar tendon rupture - description of it
defect in the inferior pole patella Large effusion Loss of active knee extension
36
Treatment for patellar tendon rupture
surgical repair with nonabsorbable sutures through drill holes in the patella
37
Quadriceps tendon rupture - normal patient population
50 years or older
38
Quadriceps tendon rupture - description of it
defect superior pole patella large effusion loss of active knee extension
39
Treatment for quadriceps tendon rupture
Surgical repair - torn retinaculum with interrupted sutures
40
Extensor mechanism disruptions - post operative rehab
need to protect the repair - crutches 4-8 wks - cast or brace protected ROM 3 months - avoid open chain quad resistance 3 months
41
Extensor mechanism disruptions - post operative rehab - full recovery
3 months for soft tissues to heal to bone in healthy lab animals 6-12 months for full recovery
42
Internal Derangement - list
``` Meniscus tear Osteochondritis dissecans Loose bodies Ligament sprain Chondromalacia - DJD ```
43
Meniscus - function
``` Fibrocartilage Load bearing Shock absorption Joint stability Lubrication ```
44
Meniscus tear - Mechanism
Traumatic | Degenerative
45
Meniscus tear - age related changes
Fraying Stable tears Necrosis CPPD
46
Meniscus tear - traumatic mechanisms
Twisting | Deep flexion
47
Meniscus tears - mechanical symptoms
locking catching popping instability - giving way, due to pain
48
Meniscus tear - exam findings
Effusion Joint line tenderness Focal swelling McMurrys test +
49
Treatment for meniscal tear
Partial menisectomy | Meniscus repair
50
Partial menisectomy
Removal of 50% or greater alters contact stress | Inc risk for degenerative changes over time
51
Meniscus tear - factors that affect healing
``` Age Location Knee stability Size of tear Ability to coapt edges ```
52
Post-menisectomy knee | Meniscus allograft reconstruction - factors that affect success
Knee stability Alignment Chondromalacia - no grade 4 changes Precise reproduction of attachment sites
53
Osteochondritis Dissecans - etiology
Trauma - acute vs overuse Vascular Variant of ossification Most say overuse
54
Osteochondritis Dissecans - description
Joint line pain Locking Effusion Radiographs demonstrate lesion
55
Osteochondritis Dissecans - Stage 1
Surface intact but ballotable
56
Osteochondritis Dissecans - Stage 2
Surface fracture but not displaced
57
Osteochondritis Dissecans - Stage 3
Fragment hinged
58
Osteochondritis Dissecans - Stage 4
Detached fragment
59
Osteochondritis Dissecans - Treatment if skeletally immature
Immobilize Activity modification Good prognosis
60
Osteochondritis Dissecans - Treatment if skeletally mature
Drilling Bone graft and internal fixation Debridement and microfracture Poor prognosis if completely detached
61
Loose body - description
Joint line pain Locking Effusion
62
Etiology - loose body
Patellar instability, fractures OCD DJD
63
Loose body treatment
Arthroscopic removal | ORIF if bone fragment large
64
Articular cartilage - mechanism
Traumatic - fall, direct blow, ligament tear, patellar instability Degenerative
65
Articular cartilage History
Pain with activity Swelling, stiffness Locking, catching, popping
66
Articular cartilage - physical exam
Joint line tenderness Effusion Might have malalignment Might have limited ROM
67
Articular Cartilage - Imaging
Radiographs normal early on Progressive joint space narrowing, osteophytes MRI - small lesions may be missed
68
Articular Cartilage - Classification Stage 1
Softening
69
Articular Cartilage - Classification Stage 2
Fibrillation (less than 50%)
70
Articular Cartilage - Classification Stage 3
Deeper fissuring (more than 50%)
71
Articular cartilage - classification stage 4
exposed bone
72
Articular cartilage - Arthroscopic debridement (chondroplasty)
Short term improvement (70% 1 yr, 50% 2 yrs) | Does not alter natural history
73
Articular Cartilage Treatment
Marrow stimulation Microfracture, drilling, abrasion arthroplasty Fibrocartilage repair
74
Articular cartialge treatment and improvement
Short term improvement (75% 5 yrs) | Does not alter natural history
75
Other treatments for articular cartilage
Osteochondral transfers OATs Mosaicplasty Fibrocartilage btw grafts
76
Articular Cartilage chondrocyte implantation
Two procedures Step 1 = chrondral biopsy (scope) Step 2 = implantation (open) Expensive
77
Articular Cartilage = DeNovo
``` Particulated juvenille cartilage Less than 13 yo Potential for healing One step procedure No long term studies ```
78
Articular Cartilage - treatment indications
``` Traumatic lesions Less than 50 yo Normal radiographs Not DJD Correctable malalignment Normal meniscus ```
79
Articular Cartilage - Treatment Algorithm | Lesions less than 2 cm
Marrow stimulation | Autogenous OATs
80
Articular Cartilage - Treatment Algorithm | Lesion more than 2 cm
ACI DeNovo Allograft OATs
81
Articular Cartilage - Treatment Algorithm | Multiple lesions
ACI DeNovo Allografts Non-op until TKA
82
Articular Cartilage Post-op Rehabilitation
``` Crutches 6 to 12 weeks 3-6 wks NWB 3-6 wks PWB Immediate ROM CPM, AROM 6-12 month recovery ```
83
Degenerative Joint Disease
Long term outcome of untreated (or treated) cartilage lesions Management depends on patient age and severity of disease TKA last option
84
Degenerative Joint Disease - Non operative treatment
``` NSAIDs, acetaminophen PT Bracing Activity modification Corticosteroid injections Controversial glucosamine, hyaluronates, PRP, stem cells ```
85
DJD - Operative treatments - Arthroscopic Debridement
Mild DJD with meniscus tear After failed non-op Rx Short term improvement
86
DJD - operative treatments - osteotomies
Unicompartment DJD Younger patients, heavy labor Delay TKA 5-10 yrs
87
DJD - operative treatments - arthroplasties
UKA | TKA
88
DJD - osteotomies - Varus knee
Tibial Closing wedge lateral Opening wedge medial Distraction Callotasis
89
DJD - osteotomies - Varus knee - Closing wedge
Lateral - no bone graft | TKA more difficult after
90
DJD - osteotomies - Varus knee - Opening wedge
Medial - need bone graft | Delayed weight bearing
91
DJD - osteotomies - Varus knee - Distraction Callotasis
External fixator | No bone graft
92
DJD - osteotomies - Valgus knee
Femoral Closing wedge medial Opening wedge lateral
93
DJD - patellofemoral DJD
Osteotomies - Tibial tubercle elevation Patellectomy - rare Arthroplasty - new implants, no long term results, older patients
94
DJD post op rehab
Immediate ROM Opening wedge osteotomy - protect WB until bone graft heals (6 wks) Tibial Tubercle - no resistance to extension 6 wks
95
DJD Arthroplasty - Unicompartment UKA
Single compartment More normal feeling knee Smaller incision 10+ yrs survivorship
96
DJD - arthroplasty - TKA
last option 15-20 yr survivorship minimally invasive
97
Mechanism for ACL injury
Twisting, pivoting Hyperextension Isolated - noncontact Combined - contact
98
ACL injury - history
Pop Knee gives out - pivot shift Rapid onset swelling
99
ACL injury - exam
Effusion + Lachman +/- Anterior drawer + pivot shift
100
ACL injury - exam | What to be aware of
Need to be aware of false pos for ant drawer and lachman due to PCL tear
101
ACL injury - diagnosis
Pivot shift test
102
ACL injury - Radiographs
Most normal Tibial bony avulsion - 2 to 4% Segond's fracture 6% - anterolateral ligament
103
ACL injury Diagnosis
``` MRI accuracy is 88-100% PE accuracy is 90-100% Instrumented measurement KT-2000 Arthroscopy ```
104
ACL injury - natural history of ACL deficient knee
Repeated giving way episodes leads to meniscus tears and articular cartilage injuries Eventual DJD No proof that surgery leads to less arthritis
105
ACL injury - Treatment depends on
``` Degree of instability Patients activity level Age If meniscuc is repairable Multi ligament Patient goals and willingness to rehab ```
106
ACL non operative treatment
Swelling control Restore ROM Hamstring strengthening Pivot shift control program
107
ACL injury - operative treatment
ACL repair + augmentation Autogenous grafts No artificial grafts Allografts
108
ACL injury - Rehab
``` Emphasize early return of ROM and full activities Ext = less than 2 wks Flex = 6 wks Closed chain ex Functional ex Less bracing Return to full function 6-12 months ```
109
PCL resists
posterior tibial displacement | Larger than ACL
110
PCL injury
``` less common than ACL (10:1) Fall onto flexed knee Dashboard injuries Hyperextension + post drawer ```
111
PCL injury - Grade 1
0-5 mm
112
PCL injury - Grade 2
6-10 mm
113
PCL injury - Grade 3
11-15 mm | Tibia subluxes behind femoral condyles
114
PCL injury - treatment if isolated tear
quad strengthening
115
PCL injury - treatment if combined ligament tear
Operative repairs/reconstruction
116
MCL injury
Valgus stress Local tenderness and swelling +/- effusion Pathologic laxity
117
MCL injury grade 1
Tender over MCL to palpation | Tender with valgus stress but no laxity at 30 degrees
118
MCL injury grade 2
Tender over MCL to palpation | Valgus stress laxity of 5-10 mm but with and endpoint
119
MCL injury grade 3
tender over MCL greater swelling and usually an effusion valgus stress laxity greater than 10mm with no endpoint
120
MCL injury - treatment
Usually non-operative with good long term results Early ROM exercises Bracing for grades 2 and 3
121
MCL injury Results of early ROM vs casting vs surgery are
equal
122
MCL injury - pediatric patients
Beware for physeal plate injuries Ligaments are stronger then physis Stress x-rays are recommended
123
Knee dislocations
Tears of ACL, PCL, and collateral ligaments | Limb threatening injury - need to do vascular studies - 10% amputation risk
124
Non operative treatment for knee dislocations
Cast or brace, low demand patients
125
Operative treatment for knee dislocations
Reconstruct ACL and PCL Repair/reconstruct collaterals Acute repair better results than chronic
126
Post op rehab for knee dislocation
Crutches TTWB 6-12 wks May restrict ROM 2-3 wks No open chain quads or hams for 6 months
127
Patella fractures mechanism
direct blow, fall onto knee, dashboard injury Disrupts extensor mechanism Variable pattern
128
Treatment for patellar fractures
Cast if less than 2 mm displaced ORIF if displaced Excise/Repair - inf pole fracture, highly communuted Patellectomy - highly comminuted
129
Patella fracture - rehab
if fixation is stable ROM early No ext against resistance until fx healed WBAT with brace
130
Patellectomy - rehab
Wait for soft tissue healing | About 6 weeks
131
Tibial plateau fracture
Falls - elderly, osteoporotic | High velocity trauma, younger patients
132
Tibial plateau fractures - non operative if
minimally displaced fx
133
Tibial plateau fracture - operative
ORIF Medial (more than 2 mm displaced) Lateral (more than 5) Bone graft
134
Tibial Plateau fractures rehab
Start ROM early Non WB for about 6 weeks Hinged brace or cast brace
135
Tibial intercondylar eminence fractures
Bicycle accidents Hyperextension or rotator mechanism 8 to 15 yrs old ACL attached to fragment
136
Tibial intercondylar eminence fracture type 1
nondisplaced
137
Tibial intercondylar eminence fracture type 2
hinged
138
Tibial intercondylar eminence fracture type 3
complete displacement
139
Tibial intercondylar eminence fracture treatment for type 1
cylinder cast or brace
140
Tibial intercondylar eminence fracture for type 2 and 3
operative reduction and fixation
141
Supracondylar femur fractures
high velocity trauma younger patients | low velocity trauma elderly osteoporotic patients
142
Supracondylar femur fractures - treatment
usually ORIF plates and screws IM rods locked
143
Supracondylar femur fractures - rehabilitation
start ROM early protect WB 6-8 wks hinged brace or cast brace

Semester 2 PM Exam 8 (5 decks)

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