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Knee Presentation
 

Knee Presentation

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    Knee Presentation Knee Presentation Presentation Transcript

    • Injuries of the Knee Joint
      Andrew Bonett
      M.S.M.S. Anatomy
      University of South Florida
      July 16, 2009
    • Gross Anatomy: Bones
      intercondylar eminence
      patellar surface
    • Gross Anatomy: Skeletal Structure
      22
    • Gross Anatomy: Articular Surfaces
    • Gross Anatomy: Menisci
      • Fibrocartilaginous structures
      • Attach to tibia in intercondylar region
      • Transverse ligament connects the anterior horns of each menisci
      • Vascular periphery (2-3 mm)
      • Medial meniscus
      • Oval-shaped
      • Attached to MCL
      • Thinner , less mobile
      • Lateral meniscus
      • Circular
      • Thicker, more mobile
    • Gross Anatomy: Synovial Membrane
      Bursae:
      • Suprapatellar
      • Subpopliteal
      • Prepatellar
      • Subcutaneous
      infrapatellar
      • Deep infrapatellar
      PCL
      MM
      LM
      ACL
      Does not invest cruciate ligaments!
    • Gross Anatomy: Ligaments
      Medial Collateral (MCL)
      Lateral Collateral (LCL)
      Anterior Cruciate (ACL)
      Posterior Cruciate (PCL)
      Meniscofemoral (MFL)
      Meniscofemoral
      ligament
    • Gross Anatomy: Muscles
      Thigh
      Quadriceps femoris – VL, VM, VI, RF
      Sartorius
      Gracilis
      Hamstrings – BF, SM, ST
      IT band – GM, TFL
      Leg
      Gastrocnemius
      Plantaris
      Popliteus
      (Pes anserinus)
    • Gross Anatomy: Popliteal Fossa
      1. Semitendinosus
      2. Biceps femoris
      3. Semimembranosus
      4. Sciatic nerve
      5. Popliteal vein
      6. Popliteal artery
      Common peroneal n.
      Tibial n.
    • Gross Anatomy: Vasculature
      • Popliteal Artery
      • Med./Lat. Superior Genicular
      • Middle Genicular – enters capsule post. to supply ligaments and synovium
      • Med./Lat. Inferior Genicular
      • Circumflex Fibular
      Patellar Plexus
      Anastomoses of descending branch of lateral circumflex femoral a., anterior tibial recurrent a., and genicular branches
    • Gross Anatomy: Nerve Supply
      Sciatic nerve
      Tibial n.
      Common peroneal n.
      Wraps around head of fibula
      Saphenous branches
      Run deep to pes anserinus
    • Patellar Dislocation
      Predisposition
      Genu valgum
      Overweight
      Patellar hypermobility
      Weak quadriceps
      Mechanisms
      Direct contact to medial side
      External tibial rotation with forceful quadriceps contraction
    • Patellar Dislocation
      Vastus medialis strain
      Tearing of medial patellar retinaculum
      Hemarthrosis
      Reduces with extension
    • Patellar Dislocation: Diagnosis
      Obvious if not yet reduced
      Patellar hypermobility/ apprehension test
      X-ray/MRI only necessary to rule out osteochondral fractures, other associated injuries
    • Patellar Dislocation: Treatment
      Knee extension
      Aspiration to relieve discomfort and check for fat in blood
      Surgery unnecessary unless osteochondral fracture or complete rupture of MPFL
      Crutches, PRICES
      Rehabilitation focusing on vastus medialis
    • Meniscal Tears
      Shear force from femur
      Acute or degenerative
      Athletes, elderly, overweight
      Vascular zone?
      Horizontal
      Within substance
      Longitudinal
      Bucket handle – ACL risk
      Radial or vertical
      Parrots beak
    • Medial Meniscus Tear
      Tears easier than lateral due to certain traits
      Squatting
      Internal rotation of tibia with knee flexed
      Member of “unhappy triad”
      Medial meniscus
      MCL
      ACL
    • Medial Meniscus: Diagnosis
      Examination
      McMurray’s test
      Apley’s compression test
      MRI
      Low-signal intensity (black triangle ) = normal
      White interruption = lesion
      Arthroscopy as last resort
    • Medial Meniscus: Treatment
      PRICES for isolated and minimal tear
      Partial arthroscopic meniscectomy most common
    • Lateral Meniscus Tear
      Lower incidence
      Often more painful
      More likely to incur radial or parrots beak
      Not rare for anterior horn
      Discoid meniscus
      Wrisberg variety
      Congenital (1.5-3%)
      MM only 0.1 – 0.3%
      femur
      Discoid meniscus
    • Lateral Meniscus: Diagnosis/Treatment
      Same techniques as for medial meniscus
      McMurray’s test and Apley’s test performed with internal tibial rotation
      MRI slightly less accurate than with MM
      Treatment similar
    • Medial Collateral Ligament
      Attached to fibrous capsule and MM
      Injury rarely isolated – “unhappy triad”
      Can tear with external rotation (skiing), but more commonly from valgus or abduction force (football)
      Pain localized to medial joint line, but can subside following Grade III tear
      Leads to further injury
    • MCL: Diagnosis: Examination
      Abduction stress test
      First at 30
      Again at full extension
      Rule out PCL tear
      Anterior drawer test with external rotation of tibia
      Hip flexed 45
      Knee flexed 90
      Tibia rotated 30 ext.
      Anterior rotation of medial tibial condyle
    • MCL: Diagnosis: Imaging
      X-ray
      Only useful for young patients to differentiate from epiphyseal fracture
      Taken at 20-30 flexion
      Enlarged joint space = tear
      MRI
      Coronal scan
      Normal MCL looks thin, taut, low-signal
      Grade I: indistinct MCL (edema)
      Grade II: thicker, looser
      Grade III: severe edema
    • MCL: Treatment
      Surgery necessary for compound injury
      Crutches + PRICES + rehab for Grade I, II onlyif isolated
      Grade III tears may require surgical repair, but immobilization can be effective if isolated (rare)
      3-4 months recovery
      Surgery
      Open incision
      Midsubstance ruptures sutured
      Tear from bone repaired with suture anchors
    • Lateral Collateral Ligament
      Courses slightly posterior
      Sprained least frequently
      Adduction force rare
      BF, popliteus, IT tract
      Flexed knee = isolated tear
      Anteromedial blow  hyperextension/ postero-lateral corner injury
      Risk to common peroneal nerve
      Foot drop, sensation loss
    • LCL: Diagnosis: Examination
      Adduction stress test
      At 30, then full extension
      Ext. rotation recurvatum
      Lift legs by great toes
      Recurvatum + ext rotation + varus = PL corner injury
      Posterolateral drawer test
      Tibia externally rotated, posterior force applied
      Reverse pivot shift test
      Knee 90, tibia ext. rotated
      With valgus, slowly extended
      Temporary posterior subluxation of lateral tibial condyle around 30
      Forcibly reduces with extension
    • LCL: Imaging and Treatment
      MRI
      Coronal oblique scan
      Sagittal scan to rule out fibular fracture, avulsion
      Tear looks less taut or discontinuous – no thickening
      Treatment
      Similar to MCL
      Grade III usually requires surgery
    • Anterior Cruciate Ligament
      Most common knee injury among athletes
      AM fibers taut in flexion
      Check anterior displacement
      PL fibers taut in extension
      Check rotation
      Hyperextension, internal rotation – rarely isolated injury from contact force
      “unhappy triad”
      May tear from tibia (3-10%), from femur (7-20%), or in midportion (70%)
      Proximal end receives branch from middle genicular a.
      (LEFT KNEE)
      Internal rotation of right knee
    • ACL: Diagnosis: Examination
      History, large hemarthrosis
      Autonomic symptoms
      Anterior drawer test
      Tibia neutral, pull ant.
      NOT RELIABLE BY ITSELF
      Lachman test
      Knee only flexed 15-20
      Pivot shift/jerk test
      Start in extension, tibia internally rotated, valgus
      Slowly flex, lateral tibial condyle temporarily subluxates anteriorly ~30
      Reduces with further ext.
      Jerk test opposite (90 o)
    • ACL: Diagnosis: Imaging
      X-ray
      Segond fracture of lateral tibial condyle
      ACL tear with it 75-100%
      Tibial spine avulsion in young patients
      MRI – 95% accuracy
      All 3 planes in full extension
      Edema/hemorrhage often obscures ACL
      Normal ACL
      Torn ACL
    • ACL: Treatment
      Extrasynovial, heals poorly
      Partial, isolated tears may be treated with PRICES, rehab, bracing of slightly flexed knee
      Most tears, athletes will require reconstruction
    • Posterior Cruciate Ligament
      Broader, longer, stronger
      PM and AL fiber bundles
      Receives better vasc. from MGA, synovial membrane
      Checks post. displacement
      Tears much less frequently
      Only in isolation when “dashboard knee” injury
      Hyperextension in sports, especially with side force
      Falling to ground with foot plantar flexed
      Posterior view
      Medial femoral condyle
      Anterior view
    • PCL: Diagnosis
      Posterior drawer test
      Neutral start vital!
      Gravity or sag test
      Hips at 45or 90, compare tibial tuberosities for sag
      Abduction/adduction stress test at full extension
      X-ray to confirm sag test
      MRI shows lower-signal intensity for intact PCL compared to ACL due to its fiber organization
      Take on all 3 axes, but best is sagittal oblique
      negative
      positive
    • PCL: Treatment
      Controversial
      PRICES , rehab, bracing for most isolated tears
      Rehab focused on quadriceps muscles for compensatory anterior drawer
      Surgery avoided when possible because PCL not easy to access without additional risk factors
      Prognosis good because better blood supply = revascularization
    • Cruciate Ligament Reconstruction
      Complete excision followed by graft insertion
      Allograft
      Autograft
      Patellar, quadriceps, hamstrings, calcaneus tendons used
      Undergoes biological modifications: inflamed, necrotic  revascularization  extrinsic fibroblasts repopulate
    • ACL Reconstruction
      Autografts
      B-PT-B
      Quadruple hamstrings
      Semitendinosus, gracilis
      Only replace AM
      Double-Bundle
      Provides rotational stability
      BTB as AM bundle
      Fixed at 20
      ST as PL bundle
      Fixed at 90
    • PCL Reconstruction
      Usually allograft – calcaneus tendon
      Incorporates well with long-term stability
      BTB and ST often too short
      Can achieve full function with reconstruction of just AL bundle
      A
      B
      A. Low-power view cross section of PCL 11 years after calcaneus tendon graft. B. High-power
    • Future of Reconstruction
      Goals:
      Improve recovery time
      Improve remodeling of insertion sites
      Improve nervous and vascular restoration
      With biological manufacture of:
      Growth factors, cytokines
      Antibiotics
      Techniques:
      Gene therapy – viral/non-viral vector delivers specific gene
      Tissue engineering – mesenchymal stem cells