Clinical perspectives of knee joint
-
Upload
navinthakkar -
Category
Health & Medicine
-
view
1.574 -
download
6
Transcript of Clinical perspectives of knee joint
![Page 1: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/1.jpg)
![Page 2: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/2.jpg)
![Page 3: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/3.jpg)
Tibiofemoral Joint – formed between tibia and femur
A HINGE JOINTPatellofemoral joint – formed between the
patella and the femur A GLIDING JOINT
![Page 4: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/4.jpg)
![Page 5: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/5.jpg)
Femurproximal – head and neck of
femur, greater trochanter
distal – medial and lateral
condyles and epicondyles
![Page 6: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/6.jpg)
Patella – largest sesamoid bone in body
Tibia – tibial plateau forms knee joint with femur
The fibula is not a part of the knee joint
![Page 7: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/7.jpg)
![Page 8: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/8.jpg)
The Quadriceps – Knee Extension
1. Vastus Medialis2. Vastus Lateralis3. Vastus Intermedius4. Rectus Femoris – 2 joint
muscle that also acts as a hip flexor
![Page 9: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/9.jpg)
![Page 10: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/10.jpg)
The Hamstrings- knee flexion
3 muscles:1. Biceps Femoris2. Semimembranosus3. Semitendinosus
![Page 11: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/11.jpg)
![Page 12: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/12.jpg)
The Adductors (Groin)Adduct the thigh
1. Adductor Longus2. Adductor Magnus3. Adductor Brevis4. Gracilis
![Page 13: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/13.jpg)
The Sartorius: - flexes,
abducts, and laterally rotates thigh
- longest muscle in the body, “tailor’s muscle”
- Crosses hip and knee joint
![Page 14: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/14.jpg)
The Iliotibial Tract(IT Band)
- neither a muscle or tendon, but a long, thick band of tissue that inserts into the lateral tibia (Gerdy’s Tubercle)
![Page 15: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/15.jpg)
![Page 16: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/16.jpg)
1. ACL – Anterior Cruciate Ligament2. PCL – Posterior Cruciate Ligament3. MCL – Medial Collateral Ligament4. LCL – Lateral Collateral Ligament
![Page 17: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/17.jpg)
![Page 18: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/18.jpg)
MCL:- Medial Collateral
Ligament- Runs from
medial femur to medial tibia
LCL:- Lateral Collateral
Ligament- Runs from lateral
femur to head of fibula
![Page 19: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/19.jpg)
![Page 20: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/20.jpg)
A “c”-shaped piece of fibrocartilage located in the knee joint between the femur and attached to the top of the tibia
Cartilage = meniscus
![Page 21: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/21.jpg)
![Page 22: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/22.jpg)
![Page 23: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/23.jpg)
Medial
- larger and more C-shaped
- more firmly attached to tibia - has attachments to MCL
Lateral
- smaller and more round or O-shaped- not firmly attached to tibia and LCL
![Page 24: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/24.jpg)
Mostly avascular – little or no blood supplyOnly the outer 20% has a blood supply* Does not have the ability to heal itself unless
there is a small tear in the outer 20%
![Page 25: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/25.jpg)
1. Stability2. Shock absorption3. Lubrication and nutrition4. Allows adequate weight distribution
![Page 26: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/26.jpg)
Normal Torn
![Page 27: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/27.jpg)
![Page 28: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/28.jpg)
TraumaFractures around kneeLigamentous sprainsMuscular strains
Degenerative conditionsOsteoarthritis of knee jointOsteochondritis dessicansTraumatic arthritis
![Page 29: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/29.jpg)
Inflammatory conditionsRheumatoid arthritisJuvenile RheumatismNeuropathic jointHemophilic arthritisBursitisOther conditions
InfectionSuppurative arthritisTuberculosis
![Page 30: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/30.jpg)
Tumors around knee jointTumors of boneTumors of soft tissue
Metabolic conditionsRicketsScurvyGoutOchronotic ArthritisOsteoporosis
![Page 31: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/31.jpg)
Congenital and Developmental conditionsGenu valgumGenu varumGenu recurvatumCongenital dislocation of patellaCongenital discoid meniscus
![Page 32: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/32.jpg)
![Page 33: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/33.jpg)
Fractures around kneeSupra condyler femur fractureFractures of the isolated condyleTibial condyle and plateau fractureFracture patellaTibial tuberosity avulsion
![Page 34: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/34.jpg)
Fractures of the femoral condyle at metaphysis level extending in to knee joint
Fractures of the isolated condyleHoffa’s FractureEpicondyler avulsions
![Page 35: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/35.jpg)
![Page 36: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/36.jpg)
![Page 37: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/37.jpg)
![Page 38: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/38.jpg)
![Page 39: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/39.jpg)
Both condyle fractures Isolated condyle fractures Tibial spine fracture
![Page 40: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/40.jpg)
![Page 41: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/41.jpg)
![Page 42: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/42.jpg)
![Page 43: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/43.jpg)
![Page 44: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/44.jpg)
![Page 45: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/45.jpg)
![Page 46: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/46.jpg)
![Page 47: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/47.jpg)
>200,000 injuries/year>100,000 reconstructions/yearHigher incidence in femalesMales = contact
Females = noncontact
![Page 48: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/48.jpg)
1. MOI: twisting of knee forced hyperextension lateral blow to knee
*foot must be firmly anchored to playing surface
2. 50% of people describe a “pop” in knee 3. Knee fills with blood quickly
Hemarthrosis4. Usually immediate loss of motion5. Knee feels unstable
![Page 49: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/49.jpg)
![Page 50: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/50.jpg)
Anterior Drawer Test:
examiner attempts to slide the tibia forward which may indicate a torn ACL ligament
![Page 51: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/51.jpg)
Who needs surgery? - Activity level? - Level of Competition - Age?
![Page 52: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/52.jpg)
ArthroscopicGraft options
Patellar TendonSemitendinosusGracilisCadaverSynthetic
![Page 53: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/53.jpg)
![Page 54: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/54.jpg)
1. MOI: excessive hyperextension hyperflexion
tibia forced posteriorly (blow to front of knee)“dashboard knee”
Possibly 90% of all PCL injuries due to motor vehicle accidents?
![Page 55: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/55.jpg)
2. Mild hemarthrosis3. Posterior knee pain4. Walk with knee
slightly flexed, avoid full extension
5. Posterior sag of tibia6. Surgery?
![Page 56: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/56.jpg)
MOI: Blow to the outside of the knee = Valgus Force Possible overuse – breaststroke in swimmers
Commonly associated with meniscal injuries – attached to medial meniscus
No surgery
![Page 57: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/57.jpg)
![Page 58: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/58.jpg)
Valgus Stress Test:tests for injury to the MCL ligament
![Page 59: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/59.jpg)
MOI: Blow to inside of the knee – Varus force
Grade III tear may require surgery
![Page 60: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/60.jpg)
![Page 61: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/61.jpg)
Varus Stress Test:tests for injury to the LCL ligament
![Page 62: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/62.jpg)
1. MOI: Rotation of the knee as the knee extends during rapid cutting or pivoting
![Page 63: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/63.jpg)
2. Signs and Symptoms:- pain- joint line tenderness- catching or locking- knee buckling or giving way- swelling- incomplete flexion- clicking on stair climbing
![Page 64: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/64.jpg)
3. Surgery?Meniscectomy: removal of the
meniscus- Total meniscectomy = osteoarthritis
Depends on location of tear, type of tear, and blood supply
![Page 65: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/65.jpg)
- bucket handle- Flap tear- Transverse tear- Horn tear
![Page 66: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/66.jpg)
![Page 67: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/67.jpg)
Apley’s Compression
![Page 68: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/68.jpg)
Tear of the medial meniscus, anterior cruciate ligament (ACL), and medial collateral ligament (MCL)
![Page 69: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/69.jpg)
Osteoarthritis of knee jointOsteochondritis dessicansTraumatic arthritis
![Page 70: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/70.jpg)
Disease of the joints characterized by:
– Progressive articular cartilage loss
– New subchondral bone formation
– New bone and cartilage formation at joint margins
– Low level synovitis
& PAIN!
![Page 71: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/71.jpg)
– Joint Pain
– Typical Pain Pattern
– Xray FindingsStanding filmsAP with 30 deg
flexion
– No Sign of Zebras
![Page 72: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/72.jpg)
Pathogenesis of Osteoarthritis
An Interplay of Factors
Dieppe, American Academy of Orthopaedic Surgeons, 1995
![Page 73: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/73.jpg)
Age10-fold increase from
3065Genetics (generalized)Gender
Men <50: higher riskWomen >50: higher
riskNutritional
Low vitamin C and D intake
Joint Biomechanical Risk FactorsJoint traumaObesity (knee, hip, hand)OccupationAbnormal joint
biomechanicsDysplasia,
malalignment, instability, abnormal innervation
Knee extensor wknessSports w/ joint risk
![Page 74: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/74.jpg)
50% decrease in OA with with 11#
wt lossLarger effect in
women (Felson et. al.
Ann Int Med 1992, Framingham Heart
Cohort data)
![Page 75: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/75.jpg)
![Page 76: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/76.jpg)
Jobs requiring repetitive knee
bending/moderate activity predict higher rates of osteoarthritis
Felson et alAnnals of Int Med 1992
![Page 77: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/77.jpg)
![Page 78: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/78.jpg)
11 lb / 50% risk reduction rule
Break that vicious cycle:
Team approach is critical
Disuse
Weight Gain
Pain and stiffness
![Page 79: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/79.jpg)
Regular aerobic walking for knee OA LOE 1a for knee OA LOE IV for hip OA
Home-based quad strength exercises LOE 1a for knee OA LOE IV for hip OA
Water-based exercise for hip OA LOE 1b
![Page 80: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/80.jpg)
Medial or lateral unloading
![Page 81: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/81.jpg)
Medial tibio-femoral OA
![Page 82: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/82.jpg)
TENS effective in some with knee or hip OA Short-term, 2-4 weeks
Acupuncture relieves pain (no effect on function)
Pulsed Electromagnetic Field Therapy Meta-analysis 2009
Thermotherapies
![Page 83: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/83.jpg)
Tylenol, max 4 gm/day analgesic of choiceLOE 1a, but modest pain relief if OA
mild/modNSAIDs—LOE 1aTramadol: LOE 1a in short-term trials
No long-term trialsMore side-effects than Tylenol
Glucosamine
No disease modifying drug for OA (yet)
![Page 84: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/84.jpg)
Considerations before treatment:Surgical candidate?
Don’t waste the timePrevious injections?
![Page 85: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/85.jpg)
Beneficial in KNEEBeneficial in HIPShort-duration benefits: 2-4 weeks
![Page 86: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/86.jpg)
Effective in knee and hip (LOE 1a)Delayed effect (1-3 weeks)Long duration (6 months)Weekly injections, 3-5xMight delay need for joint replacement
![Page 87: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/87.jpg)
X
![Page 88: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/88.jpg)
Arthroscopy Joint replacementCartilage transplantation
![Page 89: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/89.jpg)
Cochrane review 2008: NO BENEFIT for undiscriminated OA (mechanical or inflammatory causes)
![Page 90: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/90.jpg)
LOE IIIUniversally
recommended to improved pain, function, QOLUnicompartmentalTotal joint replacement
![Page 91: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/91.jpg)
![Page 92: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/92.jpg)
![Page 93: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/93.jpg)
![Page 94: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/94.jpg)
Osteo-Articular Transplant (OAT) procedures
Autologous Chondrocyte Implantation (ACI)
Cadaver allografts
![Page 95: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/95.jpg)
Due to intraarticular fractures
Malunions lead to joint arthrosis
Primary cartilage insult leading to repair by fibrocartilage and arthrosis
Treatment is TKR if tri compartmental OA
![Page 96: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/96.jpg)
In children and adolescents
Small segments of nactrotic subchondral bone
Pain stiffness and locking
Rest/ debridment of joint/ replacment
![Page 97: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/97.jpg)
Rheumatoid arthritisJuvenile RheumatismNeuropathic jointHemophilic arthritisBursitisOther conditions
![Page 98: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/98.jpg)
Synovitis chronic infl, synovial hypertrophy, effusion Destruction proteolytic enzymes, pannus Deformity articular destruction, capsular stretching,
tendon rupture
![Page 99: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/99.jpg)
nodules tendon sheath vasculitis myopathy and neuropathy reticulo-endothelial system visceral - lungs, heart, kidneys, brain, GI
![Page 100: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/100.jpg)
myopathy, tiredness, weight loss, malaise proximal finger joints wrists, feet, knees, shoulders start up pain tendon crepitus
![Page 101: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/101.jpg)
![Page 102: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/102.jpg)
joint destruction pain deformity instability
![Page 103: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/103.jpg)
![Page 104: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/104.jpg)
joint space narrowing peri-articular osteopenia erosions
![Page 105: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/105.jpg)
stop synovitis prevent deformity reconstruct rehabilitate
![Page 106: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/106.jpg)
10% improve 60% intermittent, slowly worsening 20% severe joint erosion, multiple surgery 10% completely disabled
![Page 107: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/107.jpg)
![Page 108: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/108.jpg)
Diabetes is the leading cause:1/700, 0.16-2.5% of all diabeticsUsually in the 5th or 6th decade of lifeRelated to duration and control of diabetesInvolvement includes:
Tarsometatarsal/metatarsophalangeal joints Ankles Knees Upper limbs (rare)
Giurini. Charcot's disease in diabetic patients. Postgrad Med 1991; Brower. Sinha. Neuro-arthropathy (Charcot joints) in diabetes mellitus (clinical study of 101 cases). Medicine (Baltimore) 1972; 51:191 .
![Page 109: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/109.jpg)
Reported associations: Leprosy Alcoholism Uremia Amyloidosis Pernicious anemia Syphillis (tertiary) Syringomyelia Spina Bifida Myelomeningocele Cord compression Cauda Equina lipoma
MS Poliomyelitis Connective Tissue disorder Charcot-Marie-Tooth disease Congential sensory neuropathies Ehlers-Danlos syndrome Familial dysautonomia Thalidomide embryopathy Intraarticular steroids
![Page 110: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/110.jpg)
![Page 111: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/111.jpg)
Radiographics. 2000;20:S279-S293
![Page 112: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/112.jpg)
Storey GO.Charcot joints. Rheumatol Phys Med. 1970 Aug;10(7):312-20.
![Page 113: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/113.jpg)
Problems with patella – most common cause of knee pain
Anatomy:- Patella is a sesamoid bone formed in Quad tendon- Patellofemoral joint – patella and femur- Compression forces –
<body weight during walking2.5 x body weight during stairs
![Page 114: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/114.jpg)
“Jumper’s Knee”Inflammation and degeneration of the tendon
that connects the kneecap (Patella) to the shin bone (Tibia).
![Page 115: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/115.jpg)
![Page 116: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/116.jpg)
A gradual degenerative change that occurs beneath the patella
Caused by acute trauma, repeated microtrauma, or improper alignment of the patella in the trochlear groove
Weak vastus medialis (VMO) can cause improper alignment
Prevention: strengthen quadsMinimize squats, downhill
running, biking with low seat
![Page 117: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/117.jpg)
![Page 118: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/118.jpg)
1. Painful swelling over tibial tuberosity(patellar tendon insertion)
2. Usually occurs between 9-13 years of age3. Pain increases with activity
![Page 119: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/119.jpg)
![Page 120: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/120.jpg)
Occurs where IT Band rubs over femur at the knee joint
Common in running (esp. downhill) or any activity with repetitive flexion
Hills or stairs increase painLots of IT Band stretching
![Page 121: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/121.jpg)
![Page 122: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/122.jpg)
“Baker’s Cyst”Fluid accumulation in posterior knee
(popliteal space)Patient usually complains of a mass behind
the knee
![Page 123: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/123.jpg)
![Page 124: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/124.jpg)
“Housemaid’s Knee”Tender swelling over
the kneecap (prepatellar bursa)
![Page 125: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/125.jpg)
Pes anserine bursitis is an irritation or inflammation of a bursa in your knee. The pes anserine bursa is located on the inner side of the knee just below the knee joint.
Tendons of three muscles attach to the shin bone (tibia) over this bursa
![Page 126: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/126.jpg)
Suppurative arthritisTuberculosis
![Page 127: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/127.jpg)
Bacterial: staphylococcus
streptococcus
Gonococcus
H. pneumonia
gram negative organisms
Mycobacterium:TB, atypical TB
Fungi: candida
Spirochete: lyme (borrelia burgdorfi)
Viral: HIV, Hepatitis B, C
![Page 128: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/128.jpg)
![Page 129: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/129.jpg)
![Page 130: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/130.jpg)
![Page 131: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/131.jpg)
Tumors of boneTumors of soft tissue
![Page 132: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/132.jpg)
![Page 133: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/133.jpg)
![Page 134: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/134.jpg)
Signs/Symptoms:Pain, characteristically more intense at night,
relieved by NSAIA and eliminated by excisionVertebral lesions may cause scoliosis
Age:10-30 years
Sex:M > F (2:1)
Anatomic Distribution:Nearly every location, most frequent in femur,
tibia, humerus, bones of hands and feet, vertebrae and fibula
Over 50% of cases in femur or tibiaMetaphysis of long bones
![Page 135: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/135.jpg)
Central radiolucent nidus with or without a radiodense center; surrounded by thickened sclerotic bone
![Page 136: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/136.jpg)
![Page 137: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/137.jpg)
Central hemorrhagic nidus surrounded by dense rim of
sclerotic bone
![Page 138: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/138.jpg)
Nidus contains interlacing network of osteoid and bony
trabeculae with variable amount of mineralization, lying in vascular fibrous tissue
![Page 139: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/139.jpg)
![Page 140: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/140.jpg)
Signs/Symptoms:PainGait disturbances
Age:80% of patients < 30 years
Sex:M >> F (3:1)
Anatomic Distribution:Predilection for vertebral columnMetaphysis of long bones
![Page 141: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/141.jpg)
Radiographic Findings:Similar to osteoid osteoma, though much larger (up
to 11.0 cm)
Gross and Microscopic Findings:Similar to osteoid osteoma, though much larger nidus
Ancillary Testing:N/A
Prognosis/Treatment:Curettage followed by bone graftingIf incompletely removed, tumor may recurMalignant change to osteosarcoma has been rarely
reported
![Page 142: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/142.jpg)
Most frequent primary malignant bone tumor
Malignant cells must produce osteoidMost tumors arise de novo, though others
arise in the setting of:Paget’s diseasePrevious RTPrevious chemo (especially alkylating agents)Fibrous dysplasiaOsteochondromatosisChondromatosisChronic osteomyelitis
![Page 143: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/143.jpg)
Signs/Symptoms:Pain and swellingPathologic fracture is uncommon
Age:Peak in 2nd decade with gradual decrease thereafter
Sex:M > F
Anatomic Distribution:50% arise around the kneeMetaphysis of long bones
![Page 144: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/144.jpg)
![Page 145: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/145.jpg)
![Page 146: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/146.jpg)
![Page 147: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/147.jpg)
![Page 148: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/148.jpg)
![Page 149: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/149.jpg)
![Page 150: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/150.jpg)
![Page 151: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/151.jpg)
![Page 152: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/152.jpg)
An 11-year-old male was seen in consultation for an increasingly painful distal femoral lesion associated with a soft tissue mass.
Plain radiograph shows an ill-defined destructive tumor in the distal femur. Fluffy radiodense infiltrates represent malignant tumor osteoid.
Biopsy material shows two major components of this neoplasm: highly pleomorphic cells and haphazard deposits of osteoid. Note that the malignant cells fill the spaces between osteoid deposits. Lace-like osteoid deposition is very characteristic of this neoplasm.
![Page 153: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/153.jpg)
The tan-white tumor fills most of the medullary cavity of the metaphysis and proximal diaphysis. It has infiltrated through the cortex, lifted the periosteum, and formed soft tissue masses on both sides of the bone.
![Page 154: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/154.jpg)
Benign:ChondromaOsteochondromaChondroblastomaChondromyxoid Fibroma
Malignant:Chondrosarcoma
![Page 155: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/155.jpg)
Benign tumor of mature hyaline cartilage
Most within bone (enchondroma)2 syndromes characterized by multiple
chondromas:Ollier’s disease
Multiple enchondromas, usually unilateralMaffucci’s syndrome
Multiple enchondromas associated with soft tissue hemangiomas
Both disorders have 25% risk of malignant transformation to chondrosarcoma
Enchondroma is the most common tumor of the bones of the hand
![Page 156: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/156.jpg)
Signs/Symptoms:Usually asymptomatic lesions; pain with pathologic
fracture
Age:Evenly distributed
Sex:F > M
Anatomic Distribution:50% of lesions within small bones of hands and feet
(mostly the phalanges)
![Page 157: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/157.jpg)
Localized central lytic lesion surrounded by sharp rim of sclerosis; cortex usually not involved, though
may be thin
![Page 158: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/158.jpg)
![Page 159: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/159.jpg)
![Page 160: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/160.jpg)
An incidental finding of a bone lesion in the distal femur of a 38-year old female. The lesion was completely asymptomatic.
Plain radiograph showed an intarmedullary zone of stippled and ring-shaped calcifications in the distal femoral metaphysis. This mineralization pattern with radiodense stipples and rings is characteristic of mature hyaline cartilage.
Low-power microscopic examination of the biopsy specimen shows three characteristic features of this lesion: a) vague lobularity; b) abundant cartilaginous matrix, which can be focally calcified; c) low cellularity.
High-power view shows clustered and scattered chondrocytes with small, uniform, darkly stained nuclei. Occasional bi-nucleated chondrocytes are present. Importantly, there were no mitotic figures.
![Page 161: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/161.jpg)
Ollier’s disease
![Page 162: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/162.jpg)
Composed of mature lobules of hyaline cartilage with foci of
myxoid degeneration, calcification and endochondral
ossification; may be quite cellular
![Page 163: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/163.jpg)
Ancillary Testing:N/A
Prognosis/Treatment:Solitary chondromas of long or flat bones need no
treatmentIf fracture occurs, treat with curettage and bone
graftingRecurrence unusual
![Page 164: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/164.jpg)
Most frequent benign bone tumorProbably not a true neoplasm, but rather a
tumor produced by growth of aberrant foci of cartilage on the surface of bone
Autosomal dominant disorder of osteochrondromatosis with risk of malignant transformation to chondrosarcoma
![Page 165: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/165.jpg)
Signs/Symptoms:Palpable mass of long durationPain from compression of regional structures
Age:60% of patients < 20 yearsAverage age 10 years
Sex:M > F
Anatomic Predilection:May occur in any bone; usually metaphysis of long
bones (lower end of femur, upper end of humerus and upper end of tibia are most frequent)
![Page 166: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/166.jpg)
Projection with cortex continuous with underlying bone; may be pedunculated; cartilaginous cap with frequent calcification
![Page 167: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/167.jpg)
![Page 168: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/168.jpg)
A 20-year-old male presented with a painless, hard subcutaneous mass in the popliteal fossa. He stated that the mass had been present for several years and did not change in size. Two words, "painless" and "non-growing" (or very slow growing), suggest that the lesion described here is probably benign.
Plain radiograph demonstrated a pedunculated bony outgrowth at the proximal tibial metaphysis. The lesion had a uniform, cartilagenous cap with stippled calcifications. The tibial cortex and medulla were continuous with those of the lesion.
The specimen consisted of a pedunculated lesion, 3 x 3 x 2cm, with a lobulated cartilage cap measuring up to 0.9cm in thickness
Osteochondroma, the most common benign bone tumor, is not a neoplasm but a hamartoma. It is thought to arise from a portion of growth plate cartilage entrapped beneath the periosteum during skeletal growth. These entrapped pieces continue to grow and ossify at the same rate as the adjacent bone. When skeletal maturity is reached, osteochondromas usually stop growing.
![Page 169: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/169.jpg)
![Page 170: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/170.jpg)
Rare benign tumorMost common primary epiphyseal
tumor in childrenSigns/Symptoms:
Local pain and swelling; tumors 1.0 to 7.0 cm
Age:2nd decade of life
Sex:M > F
Anatomic Distribution:Epiphysis of long bones40% in distal femur or proximal tibia
![Page 171: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/171.jpg)
Lytic lesion of epiphysis with thin sclerotic rim; thinning
without destruction of cortex
![Page 172: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/172.jpg)
Rare benign tumorSigns/Symptoms:
Pain and swelling
Age:2nd and 3rd decades
Sex:M > F
Anatomic Distribution:Metaphysis of long bones, though may abut the
epiphysis30% of tumors in tibia
![Page 173: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/173.jpg)
Eccentric, sharply defined radiolucency in metaphysis of long
bones; may destroy cortex
![Page 174: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/174.jpg)
Signs/Symptoms:Local swelling and pain
Age:Adulthood (60% between 30-60 years)Rare in childhood
Sex:M > F
Anatomic Distribution:Trunk, shoulder girdle, upper ends of femur and
humerus
![Page 175: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/175.jpg)
Ill-defined margins; fusiform thickening of shaft; perforation of
cortex
![Page 176: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/176.jpg)
![Page 177: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/177.jpg)
![Page 178: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/178.jpg)
![Page 179: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/179.jpg)
![Page 180: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/180.jpg)
![Page 181: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/181.jpg)
Myxoid Chondrosarcoma
Mesenchymal Chondrosarcoma
![Page 182: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/182.jpg)
Ancillary Testing:IHC
S100 – positive
Prognosis/Treatment:Must completely excise; biopsy leads to soft tissue
implantationRADIORESISTANT; surgery is Tx of choiceRecurrence may occur 5-10 years after primary5-year survival 80%Hematogenous metastasis to lung in high grade
lesions
![Page 183: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/183.jpg)
Giant Cell TumorEwing’s Sarcoma / Primitive
Neuroectodermal Tumor (PNET)Chordoma
![Page 184: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/184.jpg)
Signs/Symptoms:Pain, loss of mobility, fracture
Age:80% of patients > 20 years
Sex:F > M
Anatomic Distribution:Epiphysis of long bones50% around knee with most in distal femurMost common primary epiphyseal tumor of adults
![Page 185: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/185.jpg)
![Page 186: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/186.jpg)
A 45-year old female presented with increasing pain and swelling around the knee. She mentioned that the symptoms had progressed over a 4-month period. Age of the patient is an important diagnostic clue. If a pathologic fracture is excluded, pain and swelling imply active growth of the lesion. Plain film demonstrates a
large, lobulated, ill-defined lesion centered in the distal femoral metaphysis. There is endosteal scalloping and periosteal thickening. Central stippled and "ring and arc" calcifications are apparent and are typical of cartilaginous matrix. Small radiolucent areas are seen at the periphery of the lesion.
Low magnification shows a moderately cellular, lobulated cartilaginous tumor.
High-power view shows scattered plump, moderately pleomorphic chondrocytes. Binucleated cells are present. Mitotic rate averaged 1 per 10 hpf.
![Page 187: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/187.jpg)
![Page 188: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/188.jpg)
![Page 189: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/189.jpg)
Tumor
Geographic and Expansile
Sharp Zone of Transition between Tumor and Normal Bone/Fibula
![Page 190: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/190.jpg)
CT scan shows a thin cortical shell around the tumor indicating the periosteum is intact and the tumor is likely benign
There was no ossification or calcification within the tumor indicating that the tumor was probably not a bone or cartilage producing tumor
![Page 191: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/191.jpg)
Peroneal Nerve
Tumor
Peroneal Muscles
Soleus Muscle
![Page 192: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/192.jpg)
Signs/Symptoms:May simulate osteomyelitis as patients often
present with pain, fever and leukocytosis
Age:5-20 years
Sex:M > F
Anatomic Distribution:Long bones of extremities
Gross Findings:Solid masses of degenerating gray-white tumor
![Page 193: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/193.jpg)
![Page 194: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/194.jpg)
Signs/Symptoms:Usually found incidentally; may cause pain
Age:Children and adolescents
Sex:M > F
Anatomic Distribution:Metaphysis of long bones, usually distal femur and
tibia
![Page 195: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/195.jpg)
![Page 196: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/196.jpg)
Genu valgumGenu varumGenu recurvatumCongenital dislocation of patellaCongenital discoid meniscus
![Page 197: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/197.jpg)
Genu Valgum: “knock knees”
![Page 198: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/198.jpg)
Genu Varum: “bowlegs”
![Page 199: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/199.jpg)
Genu Recurvatum:
hyperextension of the knee joint
![Page 200: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/200.jpg)
Dislocation usually occurs as a result of sudden direction changes while running and the knee is under stress or it may occur as a direct result of injury.
Usually lateral
![Page 201: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/201.jpg)
Rehab: strengthen quads, especially VMO to hold patella in place
Each dislocation will damage cartilage which can eventually lead to traumatic arthritis
![Page 202: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/202.jpg)
![Page 203: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/203.jpg)
RicketsScurvyGoutOchronotic ArthritisOsteoporosis
![Page 204: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/204.jpg)
![Page 205: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/205.jpg)
Mineralization defect are classified according to the mineral deficiency.
Calcipenic rickets ( vit D↓, 1-alpha hydroxylase defect, vit D receptor dysfunction, dietary Ca ↓, CRF) .
Phosphopenic ricket: Inadequate intake (Premature infants (rickets of prematurity) , Aluminum-containing antacids).
![Page 206: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/206.jpg)
Deficient Intake: Ca, Ph, Vit D.
Poor absorption: vit D ↓, pseudo vit D↓, vit D resistance, high phytin content( soy formula), antacids, anticonvulsants, renal insufficiency, Fanconi syndrome, hepatic insufficiency, fat malabsorption (cystic fibrosis).
Increased excretion: furosemide, renal tubular dysfunction( phosphaturia, RTA with hypercalciuria), renal tubular damage e.g. cystinosis, tyrosinosis, galactosemia, fructose intolerance, wilson disease.
Local effect on bone matrix: hypophosphatasia(alp↓)
![Page 207: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/207.jpg)
VITAMIN D DISORDERS Nutritional vitamin D deficiency; Congenital vitamin D deficiency; Secondary vitamin D deficiency; Malabsorption ; Increased degradation; Decreased liver 25-hydroxylase; Vitamin D-dependent rickets type 1; Vitamin D-dependent rickets type 2 ;Chronic renal failure.
CALCIUM DEFICIENCY Low intake Diet Premature infants (rickets of prematurity) Malabsorption Primary disease Dietary inhibitors of calcium absorption
PHOSPHORUS DEFICIENCY Inadequate intake Premature infants (rickets of prematurity) Aluminum-containing antacids
RENAL LOSSES X-linked hypophosphatemic rickets; Autosomal dominant hypophosphatemic rickets; Hereditary hypophosphatemic rickets with hypercalciuria; Overproduction of phosphatonin ( Tumor-induced rickets, McCune-Albright syndrome’ Epidermal nevus syndrome, Neurofibromatosis) ,Fanconi syndrome, Dent disease
DISTAL RENAL TUBULAR ACIDOSIS
![Page 208: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/208.jpg)
Skeletal findings:
1. Delay in closure of the fontanelles.
2. Parietal & frontal bossing.
3. Craniotabes ( soft skull bones).
4. Enlargement of the costochondral junction (rachitic rosary).
5. The development of Harrison sulcus ( caused by pull of the diaphragmatic attachments to the lower ribs).
6. Enlargement of the wrist & bowing of the distal radius & ulna.
7. Progressive lateral bowing of the femur & tibia.
![Page 209: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/209.jpg)
GENERAL Failure to thrive; Listlessness; Protuding abdomen; Muscle weakness (especially proximal); Fractures.
HEAD Craniotabes; Frontal bossing; Delayed fontanelle closure; Delayed dentition; caries; Craniosynostosis
CHEST Rachitic rosary; Harrison groove; Respiratory infections and atelectasis
BACK Scoliosis ,Kyphosis ,Lordosis
EXTREMITIES Enlargement of wrists and ankles; Valgus or varus deformities Windswept deformity (combination of valgus deformity of 1 leg with varus deformity of the other leg); Anterior bowing of the tibia and femur; Coxa vara; Leg pain.
HYPOCALCEMIC SYMPTOMS Tetany ; Seizures; Stridor due to laryngeal spasm
![Page 210: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/210.jpg)
Extraskeletal manifestation of rickets vary depending upon the 1ry mineral deficiency.
Hypoplasia of the dental enamel is typical for hypocalcemic rickets, whereas abscesses of the teeth occur more often in phosphopenic rickets.
Hypocalcemic seizures, decreased muscle tone leading to delayed motor milestones, recurrent infections, increased sweating.
![Page 211: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/211.jpg)
![Page 212: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/212.jpg)
![Page 213: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/213.jpg)
![Page 214: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/214.jpg)
![Page 215: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/215.jpg)
![Page 216: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/216.jpg)
![Page 217: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/217.jpg)
![Page 218: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/218.jpg)
AntioxidantNot produced in the human bodyNecessary for collagen synthesisProlyl and lysyl hydroxylaseProcollagen triple helix4-8 months of deficiency to develop clinical
signs
![Page 219: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/219.jpg)
Figure 2 : Corkscrew hair [3]
Figure3: gingivitis
![Page 220: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/220.jpg)
![Page 221: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/221.jpg)
Male>>>FemaleAssociated conditions
Hyperlipidemia, obesity, HT, CAD, DMPrecipitating Conditions
ETOH, dietary excess, traumaStress: surgery, GI bleed, MIDrugs: low dose ASA, diuretics, allopurinol
![Page 222: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/222.jpg)
![Page 223: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/223.jpg)
![Page 224: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/224.jpg)
![Page 225: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/225.jpg)
Clinical:Monoarticular ->Cluster ->Polyarticular1st MTP > 90%; any jointPeaks in 12 hoursRed, hot, swollenVery painfulDesquamation of skinTophi
![Page 226: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/226.jpg)
Soft tissue swelling; tophi1st MTP -> any jointOverhanging edgeDestructive +++ if not treated
![Page 227: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/227.jpg)
![Page 228: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/228.jpg)
![Page 229: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/229.jpg)
Aspirate the joint and look for MSU crystals under polarized microscopy
![Page 230: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/230.jpg)
![Page 231: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/231.jpg)
![Page 232: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/232.jpg)
![Page 233: Clinical perspectives of knee joint](https://reader038.fdocuments.us/reader038/viewer/2022102805/554b55f1b4c9051b458b495a/html5/thumbnails/233.jpg)