Knee Sports for PostGrad Orth Course 2017
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Transcript of Knee Sports for PostGrad Orth Course 2017
POSTGRAD ORTH Deiary Kader
SPORTS INJURIES/ KNEE
FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader Knee Surgeon
South West London Elective Orthopaedic Centre Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva)
Research/Training War Trauma Elective
Postgraduate Orthopaedics
CHARITY
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PLAN1. MENISCUS
2. ACL
3. MCL
4. PCL
5. PLC
6. MULTI LEGAMENT
7. PFJ
CLINICALS ?
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Nerve Supply-KneeTibial Nerve Medial and Middle GB Common Peroneal N Lateral & Recurrent GB Obturator N - GB
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BLOOD SUPPLY- KNEEFemoral Popiteal A
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MENISCAL RESECTION & REPAIR
Fibro-cartilaginous Type I collagen
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➢ Lateral Meniscus
–Circular
–Close insertions
–Posterior = Anterior width
–Loosely attached to capsule
➢ Medial Meniscus
– Semicircular
–Wider Posterior
–Firmly attached to capsule
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Composed of 70% water - 30% organic matter (Collagen constitutes 75%)
Radial Fibres, serving as “ties” that resist shearing or splitting.
Circumferential Fibres run parallel to resist hoop stress during weight bearing.
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Compression to radial to be contained by the Menx
Meniscus Vascular Supply
Red
Red-White White
At 10 years of age
What is the function of the Meniscus?
Meniscal FunctionLoad /transmission/ distribution
50% in extension
90% in flexion
Post.Horn in >90º flexion
Lateral > Medial
Joint stability
Congruity
Lubrication/ Nutrition
Proprioception
Increase contact area and reduce contact stresses
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Meniscal Tear Management :-
Excision 60% of people over 65yrs have incidental tears
Repair
Transplant
Replacement
Traumatic tears & Degenerative tears
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Arthroscopy Papers1- N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. Sihvonen R 2- CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. Khan M
3-BMC Musculoskelet Disord. 2013 Feb 25;14:71. doi: 10.1186/1471-2474-14-71. Arthroscopic partial meniscectomy in middle-aged patients with mild or no knee osteoarthritis: a protocol for a double-blind, randomized sham-controlled multi-centre trial. Hare KB
4-Am J Sports Med. 2013 Jul;41(7):1565-70. doi: 10.1177/0363546513488518. Epub 2013 May 23. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.Yim JH
5-Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):358-64. doi: 10.1007/s00167-012-1960-3. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Herrlin SV
6- N Engl J Med 2002; 347:81-88July 11, 2002DOI: 10.1056/NEJMoa013259 A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. J. Bruce Moseley
7- Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms, BMJ 2015; 350 doi: JB Thorlund
Moseley 2002 & Thorlund 2015
Repair
Excise
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Horizontal cleavage tear
Pisani’s sign
The cyst size decrease
with knee flexion
knee flexed <45º
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DD - Cyst • Ganglia: superficial, not as hard and unconnected to the joint
• Calcified deposits in the collateral ligament: show on radiographs
• Prolapsed torn meniscus (pseudocyst)
• Sebaceous cyst
• Bursitis
• Various tumours: sarcoma, lipoma, fibroma and histiocytoma
• PVNS
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Snapping knee in deep
flexion
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Snapping knee in deep flexion
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Meniscal repairWhen would you repair a menx
Factors to consider
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Meniscal repairFactors to consider:
1. Patient
2. Chronicity
3. Type
4. Location
5. Tissue quality
6. Stability of knee
7. Axial alignment
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Meniscal repair Techniques
1. Inside-out vertical mattress suture (gold standard)
2. Outside-in
3. All-inside
4. Overall 75-90% success
5. New research
1. Better devices
2. Biologic healing/augmentation
3. Growth factors/Stem cell therapy
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Partial Meniscal Substitutes Engineered constructs
Polyurethane polymeric implant (Actifit®)
Synthetic Scaffold
Collagen Meniscus Implant (CMI®)
Collagen(CMI®)
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Collagen Menx implant
Rodkey et al
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hydrogels knee
?
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Total meniscal prosthesis
NUsurface
Synthetic implant
meniscus-like
Prof Zorzi from Verona
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Menx Allograft IndicationsSymptomatic
Neutral alignment
Normal stability
No more than grade II-III Cartilage damage
Understand the risk of disease transmission
No knee abuser and
Not in BMI >35
Prof Deiary Kader
Traumatic Chondral Damage
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Outerbridge Arthroscopic Grading System
Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II
Partial thickness defect, fissures < 1.5cm diameter <50%
Grade III
Fissures down to subchondral bone, diameter > 1.5cm. >50%
Grade IV
Exposed subchondral bone
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ICRS<1.5cm
>1.5cm
The modified International Cartilage Repair Society (ICRS)The Outerbridge classification
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Traumatic Chondral Damage
Treated with Microfracture
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MACI
Microfracture
Effective in smaller lesions
Leads to fibrocartilage production,
ACI
Greater proportion of hyaline-like tissue
Effective in larger lesions.
MACI
Technically less challenging than ACI
For big lesions > 4 cm2
More effective than microfracture.
J Bone Joint Surg Br. 2005 May;87(5):640-5.
Autologous chondrocyte implantation versus matrix-induced
autologous chondrocyte implantation for osteochondral
defects of the knee: a prospective, randomised study
.Bartlett W1, Skinner JA, Gooding CR, Carrington RW, Flanagan AM, Briggs TW, Bentley G.
We conclude that the clinical, arthroscopic and histological outcomes are
comparable for both ACI-C and MACI. While MACI is technically attractive,
further long-term studies are required before the technique is widely adopted
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ACL InjuriesFRCS(Tr&Orth) Revision Course
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Anatomy➢33 mm long, 11 mm in diameter
➢Two bundles
➢AM bundle – tighten in flexion (Translation)
➢PL bundle – tighten in extension (Rotation)
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ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the anterolateral ligament is a stabiliser of internal rotation
in >35º of flexion .
THE ACL Prevents Internal Rotation of th
e Tibia
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Valgus + ER
POP
Causes of Injury
Mechanisms of Injury:
1) “plant-and-cut” manoeuvre
2) Knee Hyperextension (Fall backwards)
3) Landing on one leg following a jump
(Olsen et al 2004)
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McDaniel – Rule of Thirds
One-third is able to compensate, and can
pursue normal recreational sports
One-third is able to compensate but will have to
reduce their sporting activities
One-third does poorly and develop instability
with simple activities daily living
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Surgical TreatmentIndications:
1) Subjective instability (non-coper)
2) ACL tear in children and adolescents
3) Multiligament injury
4) Displaced meniscal tears
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ACL Evidence-Based Review
Factors affecting results:
Patient Selection Tunnel placement Strong graft choices Solid fixation Rational rehabilitation
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Surgical Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972) Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern regarding its effectiveness in addressing anterior translation
Intra-articular reconstruction. Current best practice
Intra + Extra articular reconstruction
Hamstring BTB
Grafts / Fixations
Quads
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●Biologically inactive
●Slower incorporation
●Less stability in 6 months
●Risk of disease transmission
●Role in revision surgery
●Weaker after having been irradiated
Allograft
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➢ ◊
Paul F. Segonda Paris surgeon
1879
Prof Deiary Kader
ANTEROLATERAL LIGAMENT
ALL
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In 1972, D. L. MacIntosh In 1967,1975, M. Lemaire
Extra-articular reconstruction
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OPEN ALL Recon
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Anatomic Single bundle recon
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5mm +
What are the complications of ACL
reconstruction?
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Complications
➢ Infection
➢ DVT and PE
➢ Osteoarthritis
➢ Cyclops lesion residual tissue anterior to
the ACL blocks extension
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Complications
➢Failure of Fixation
➢Graft rupture from impingement
➢Flexion contracture and arthrofibrosis
➢Anterior placement of the femoral tunnel limits flexion
➢Anterior placement of the tibial tunnel limits extension
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ACL Tunnels
Tibial Eminence Fracture Meyers and McKeever classification (1959)
❖ Type I: non displaced
❖ Type II: partially displaced or hinged
❖ Type III: completely displaced (Type III)
❖ Type IIIA (Zifko) involves the ACL insertion only
❖ Type IIIB (Zifko) includes the entire intercondylar eminence.
❖ Type IV (Zaricznyj 1977): comminution of the fracture fragment.
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Meyers and McKeever classification (1959)
Treatment
• Casting in extension for type I
• Open reduction and internal fixation.
• Arthroscopic reduction and fixation
• Rarely ACL reconstruction is necessary
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Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course
MCL
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Medial Collateral Ligament
In 25-30° of flexion, the MCL provides 80% of the support to
valgus stress
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MCLTreatment Acute isolated MCL tear I RICE, physiotherapy. 2 Wks II ?Hinged brace for symptom improves, WBAA,
2wks III Hinged brace 30-90 or Surgical 3-4 wks
Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III
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Chronic MCL Injury
Patient A MCL Reconstruction with AT + Revision ACLR
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PCL and PLC
Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course
drive thru”
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PCL Average length of 38 mm and diameter of 13 mm
AL Bundle: Long, thick, Large part
Tightens in flexion
PM Bundle: Tight in extension
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament
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PMB tight in Extension
ALB
TIGHT IN FLEXION
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a. Ant Meniscofemoral lig Humphrey
b. Post Meniscofemoral lig Wrisberg
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament
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PCL Diagnosis in MRI ?MRI & PCL
➡ Clinical examination is more reliable than MRI scan ➡ The PCL may be dysfunctional despite normal MRI ➡ Kneeling stress x-ray ➡ Measure the degree of translation
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Surgical reconstruction 1. Indications
2. Acute combined injuries
3. Acute bony avulsion
4. Symptomatic chronic PCL
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PCL Reconstruction
PTS BRACE POST OP-PCL
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What are the structures in the Posterolateral Complex of the Knee?
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Posterolateral Complex
Posterolateral Complex Components:
– LCL, Popliteus, Popliteofibular ligament, arcuate ligament, ITB, Biceps
Function
– Resists External and Varus rotation
Mechanism of Injury
– Direct blow to anteromedial tibia
– Hyperextension/varus
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What is the function of the Posterolateral
Complex of the Knee?
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The Posterolateral Corner Summary
Primary stabilisers of external tibial rotation at all knee flexion angles
Secondary restraints to anterior and posterior translation
The Posterolateral Corner Resist Ext Rotation of Tibia
The LCL is a cord like structure 5-7 cm in lengthS
Primary static restraint to varus opening of the knee
Secondary restraint to posterolateral rotation
The popliteus is a static and dynamic external rotation stabiliser.
The popletiofibular ligament acts as
a primary restraint to external rotation of
the tibia on the femur at 30º of flexion85
The Posterolateral Corner (PLC)
Isolated PLC sectioning produce a maximal
Average increase of 13° of tibial ER at 30° of knee flexion
Average increase of 5.3° of tibial ER at 90°
Isolated PCL sectioning has no effect on external tibial
rotation
Combined injury to the PCL and PLC leads to ER of 20.9°
at 90° of knee flexion
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DIAL TEST
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Posterolateral Complex Injury
External rotation testDial Test
Increased External rotation (30º, 90º).
External rotation recurvatum
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Posterolateral Complex Injury--Treatment
Partial
– Grade I & II Instability with a good end point
– Nonsurgical Treatment
– 1-3 week immobilisation in extension
Complete Acute
– Primary repair best
– Augment with allo/auto graft
Complete Chronic
– Reconstruct Popliteus and LCL
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PLC Reconstruction The reconstruction can be:-
1. Fibula based such as modified Larson’s technique or
2. Combined tibia and fibula based such as LaPrade’s (anatomical reconstruction).
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Knee dislocationAny triple-ligament knee injury constitutes a frank dislocation. This is relatively rare but a severe and potentially limb-threatening injury.
High-energy injury such as RTA Sporting accident
May be missed on initial assessment.
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Vascular injury associated with fractures or dislocations – BOAST 6
ABCs, manage catastrophic haemorrhage
Re-align the pulseless, deformed limb
A de-vasularised limb requires surgical interventionWarm ischaemia time >3-4 leads to irreversible damageImaging options include duplex, angiography, CT angio, on-table angio
Sequence – temporary shunt, skeletal stabilisation then definitive reconstruction with autologous vein grafts
Note:- Reperfusion may lead to compartment syndrome and myoglobinuria
Vascular Injuries Previously it was thought there was a
50% incidence of vascular compromise
Now 3.3-18%
20%–30% incidence of nerve injury.
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Classification of Knee Dislocation Based on tibial displacement
➢Closed or open
➢High or low energy
➢Dislocation or subluxation
➢Neurovascular involvement
➢Anterior (common, associated with intimal tears)
➢Posterior; also medial, lateral (highest rate of peroneal
nerve injury) and rotatory (usually irreducible) or combined
➢ Hyperextension leads to anterior dislocation
➢ Dashboard injury leads to posterior dislocation95
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Classification Classified on the basis on tibial displacement in respect to the femur
ExaminationValgus and varus laxity
Anteroposterior translation
Recurvatum
>10º hyperextension suggests ACL injury
>30º hyperextension indicates PCL injury
Rotation indicates MCL and LCL injury
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ManagementSurgical emergency
Deal with life-threatening injuries first
Circulation check in A&E
Serial examination for 48 hours.
Ankle brachial Index (ABI) <0.9 is suggestive of significant
arterial injury
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Management Emergency
Deal with life-threatening injuries first
Serial examination for 48 hours.
Ankle brachial Index (ABI)
ABI <0.9 is suggestive of significant arterial injury
Involve the vascular surgeon
Radiography before manipulation
(assess direction and associated fracture)
Reduction as soon as possible in theatre
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ManagementSurgery as soon as the vascular surgeon allows Most ACL/PCL/MCL can be treated with bracing the MCL followed by combined ACL/PCL reconstruction once range of movement is restarted, usually after 6 weeks.
ACL/PCL/posterolateral corner can be treated by repairing the posterolateral corner acutely (within three weeks) and delayed ACL/PCL reconstruction 8 weeks later. Or all in One
Open dislocation, fracture dislocation and vascular compromise require staged procedures.
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Patellar DislocationRe-dislocation rate is very high
After First Time 17-20% (to 49%)
After Second Time 44%-71%
High dissatisfaction following conservative Rx
Can be confused with ACL rupture
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MPFL
VMO
VMO
MPFL
VMO
Patella Quads TendonPatella
Tendon
Medial Knee
M.E
Add.Tub
Femur
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Med Epicondyle
Add Tubercle
Patella
MPFL
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Why the patella is unstableLower limb Malalignment?? Femur, tibia or foot pronation Osseous abnormalities?? Patella alta Increased Q angle Trochlea dysplasia Soft Tissue?? HMS MPFL Insufficiency Muscle or ITB
Gait ??
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PFJ BiomechanicsPatellofemoral joint reaction force
WALKING 0.5xBW
STRAIGHT LEG RAISE 0.5xBW 0 DEG
CYCLING: 1.2 × BW
RISING FROM A CHAIR w ARMS: <3 × BW
STAIRS (UP OR DOWN) 3.3xBW 60 DEG
JOGGING & SQUAT–RISE 6xBW at 140 deg
SQUAT–DESCENT 7.6x BW at 140 deg
JUMPING UP TO 12 × BW
Ff
Ft
Fj
Trigonometry Fjf=Ff cos(angle/2)
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Knee assessmentLeg Alignment Varus/valgus
Femoral neck anteversion
Tibial rotation
Ligament assessment (ACL,PCL, MCL, LCL)
Meniscal assessment
Medial/ Lateral compartment OA
Hip , Spine, peripheral pulses
Apprehension test
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Patella AssessmentBeighton Score 0---9 Patella Alignment (Q Angle) Dislocation in extn (J Sign) Quads Bulk/ ITB (Ober's test) Hamstring Tightness Patella height Alta/Baja Patella Mobility (N@300=<1/2) Parapatellar tenderness Patella Apprehension PFJ Crepitus PFJ Compression (Clarke test) Trochlea Depth Normal (1380)
Shallow ,Flat , Convex , Cliff
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Beighton Score 0---9
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Imaging of the patellofemoral joint
✦ AP and Lateral Knee x-ray
✦ Merchant’s view
✦ MRI Axial view
✦ CT Rotational Profile
Merchant’s
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Trochlea dysplasia
Blumensaat's line
Normal Trochlea Depth
NORMAL
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Measuring patella HeightCaton – Deschamps index =1.2
Blackburne-peel index = 1.12
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MPFL injury
Patella pain
Articular Damage
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Rotational Profile CT Evidence based intervention
Femoral Anteversion N=50 -150 Knee rotation N=30 External Tibial torsion 250-300 TT:TG offset (N= 10-19mm) Patella index Patella Tilt (N=average QD&QC <200) Trochlea Tilt (N>130) Trochlea Depth Normal (1380+/- 60)
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analysis
Normal measure is 5° to 15°
Femoral anteversion
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LATERAL PATELLAR TILT
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lateral trochlear tilt
The pathologic measure is <14°
POSTGRAD ORTH Deiary Kader Clinique de la Sauvegarde –
analysis
lateral tibia twisting
slices n°3 and n°4
Normal Ext rotation is 25° to 30°
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True Q angle, Measurement of the Tibial Tuberosity-Trochlear Groove (TT/TG) distance
Normally TT/TG = 2-9 mm pathologic measure is > 19 mm
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Trochlear Dysplasia
Dejour classification of trochlear dysplasia CT
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Dejour classification of trochlear dysplasia on CT scansShallow flat
dome-shaped medial ‘‘cliff-face.’’
Dejour classification
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Non-Surgical treatment of Patella Instability
Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait
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Tibial Tubercle Transfer Patellofemoral Instability with Malalignment
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Fulkerson's Technique of Anteromedialization
A steeper osteotomy plane will produce more anteriorization along with
medialization
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PATELLA ALTADistal transfer (Distalization)
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14 mm
Patella alta
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Med Epicondyle
Add Tubercle
Patella
MPFL
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Our Dissection
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What are the complications of MPFL reconstruction?
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Trochlea dysplasia
TROCHLOPLASTY
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24 years old female doctor had a permanents dislocation of the patella Treated with 1. Lateral release 2. Tib Tub Medialisation 3. Tib Tub Distalisation 4. Trochleaoplasty 5. MPFL Reconstruction
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Surgical OptionsInstability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
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LONDON COURSE 2-7 OCTOBER 2017
UCLH