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Knee pain

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    Knee pain Knee pain Document Transcript

    • THE PAINFUL KNEEAbout The AuthorDr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”an NGO involved in the field of patient education regarding arthritis. Besides providingliterature to patient & conducting symposiums, the institute is also engaged in creatingpatients “Self Help Group” at every district level. The institute also conducts a certificatecourse for healthcare professionals & provide fellowship to experts in the field of arthritis.The author has many publications to his credit in various journals. He has also written a book “ The Basics Of Arthritis” for healthcare professionals.The author can be contacted at:Dr manoj R. kandoiC-202/203 Navare ArcadeShiv Mandir Road, Opposite Dena BankShiv mandir Road, Opposite Dena bankShivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501State: Maharashtra Ph: (0251)2602404 Country: IndiaMembership Application forms of the IACR for patients & healthcare professionalscan be obtained from.Institute of Arthritis Care & PreventionC/o Ashirwad HospitalAlmas mension, SVP Road, New Colony,Ambarnath(W) Pin:421501 Dist: ThaneState: Maharashtra Country: IndiaPh: (0251) 2681457 Fax: (0251)2680020Mobile ;9822031683Email: drkandoi@yahoo.co.inCONTENT1 Common causes of knee pain2 History Taking3 Physical examination4 Common causes of anterior knee pain, treatment protocol5 Chronic knee swelling6 Cystic swelling around knee joint7 Deformities around knee joint8 Clicking of knee joint9 Medial joint line pain10 Lateral joint line pain11 Tuberculosis of knee
    • 12 Internal derangement of knee13 Osgood schlatter disease14 Loose bodies in knee joint15 Chondromalacia patellae16 Recurrent dislocation of patella17 Fractures of patella: Classification18 Uncommon causes of knee pain19 Locking of knee joint20 Causes of Haemarthrosis21 Stiffness in the joint22 Clinical presentation of meniscus tear23 Clinical presentation of GCT.24 Tumors around knee joint25 Important Terminologies Related To Sports Injuries26 Arthroscopy of Knee Joint27 Osteochondritis Dessicans..28 Radiology of knee jointIntroduction: Knee joint is the major weight-bearing joint of the body, with certain peculiarcharacteristics: 1. It is a compound synovial joint (comprising of ‘saddle type’ patellofemoral joint & ‘Hinge type’ femorotibial joint). 2. Since it is a superficial joint it is more prone to injuries 3. The stability of the joint is mainly provided by soft tissue, not bones. The soft tissue includes cruciate ligaments, collateral ligaments, capsule & quadriceps muscle. 4. The joint has a large synovial space & many bursa around it, which could get involved in pathological processes. 5. Besides flexion & extension, slight rotational & sideward movements are possible in knee. 6. Menisci, the intra-articular structure are common source of symptoms. 7. The knee joint is normally in 7 valgus (F>M)
    • 3.1 COMMON CAUSES OF KNEE PAIN:A. Traumatic: The injury sustained is dependent upon mechanism of injury.Index 3.1: Mechanism of injury Type of injury Hyperextension Anterior cruciate tear (ACL tear) Varus LCL & ACL tear Valgus MCL & ACL tear Torsion Meniscal tear[LCL: Lateral collateral ligament, MCL: Medial collateral ligament]Other injuries include fracture of patella, tibial condyle, femoral condyle & posterior cruciateligament tear.B. Inflammatory: Synovitis, bursitis, tendonitis.C. Vascular disorders: Osteonecrosis, sickle cell crisis, haemophiliaD. Degenerative: Osteoarthritis, meniscal degeneration.E. Neoplastic: Primary or metastatic bone & soft tissue tumours around the knee.F. Referred pain: From hip or spinal lesion.3.2 HISTORY TAKING IN KNEE PROBLEMS. 1 Age (Various disease in various age groups) :Index 3.2: Age Wise Distribution: Age Common Clinical Conditions 0-12 Discoid lateral meniscus 12-18 - Osteochondritis dissecans - Early episodes of recurrent dislocation of patella - Osgood schlatter’s disease 18-30 - Meniscal tears - Chondromalacia patellae - Recurrent dislocation of patella 30-40 - Rheumatoid arthritis > 40 - Rheumatoid arthritis - Osteoarthritis - Degenerative meniscus lesions 2 Sex: Certain diseases like recurrent dislocation of patella, chondromalacia patellae & fat pad injuries are more common in females
    • 3 Swelling 4 Injury: The degree of violence, nature & direction of injury should be inquired. One should inquire whether the patient was able to finish his task after injury, whether he was able to bear weight, whether there was bruising or swelling after injury. 5 Giving Away: Giving away on twisting movements or walking on uneven surfaces may suggest cruciates or meniscal injury. 6 Locking: Locking only occurs in varying degree of flexion in cases of meniscus lesion, loose bodies & dislocating patella. The dislocating patella is associated with deformity. Locking due to torn meniscus occurs in last 10 to 40 of extension & unlocking is usually associated with a click. 7 Pain: The site, type of pain, exacerbation & relieving factors etc should be inquired.Index 3.3: Common presenting symptoms & possible etiology: Symptoms Possible Etiologies Swelling synovitis, tendinitis or bursitis Clicking or crackling sound Meniscal tear, chondromalacia patellae Locking of joint Meniscal tear, chondromalacia patellae Giving away or buckling ACL tear, patellofemoral disorder Audible pop at the time of injury ACL/ PCL injury, meniscal tear3.3 PHYSICAL EXAMINATIONPhysical examination of the patient is done with both lower limbs exposed from the front, sides &back.A. Inspection: a. Shape b. Alignment of the knee: Tibia vara or valgus malalignment, genu recurvatum c. Gait d. Wasting of thigh muscles e. Presence of swellingB. Palpation:1. Knee Joint Swelling: It may occur due to following: A. Increased synovial effusion in the joint which may be due to a. Synovial fluid b. Pus c. Blood B. Inflamed synovial tissue C. Hypertrophied synovium e.g. in chronic conditions such as RA, tuberculosis etc.Types of knee joint swelling:1 Small: It is usually associated with bulging on both sides of patellar ligament.2 Medium: Besides bulging on both sides of patellar ligament there is obliteration of the hollows at medial & lateral parapatellar ridges.3 Large: besides above mentioned finding there is distension of suprapatellar pouch4 Localised swelling: These will be dealt with later.Features of synovial hypertrophy Vis – à - Vis synovial effusion:1 Usually felt at the suprapatellar pouch2 Fluctuation test is negative3 Boggy feeling on palpation4 Presence of local warmth in synovial hypertrophy which may or may not be present in effusions.Clinical Tests For Synovial Effusion:
    • These Tests Include: a. Patellar tap test b. Fluid displacement test c. Fluctuation test a. Patellar Tap Test: From 15 cm above the patella, any excess fluid out of the suprapatellar pouch is driven back into the joint by sliding down firmly with index finger & thumb. Tip of the thumb & three fingers of the examiner’s free hand are placed squarely on the patella & a quick “Jerk” is given downwards. A click can be heard as patella strikes on the femoral condyle & “bounces” back. The test is negative in small & tense swelling (i.e. when effusion is either too less or too much) b. Fluid Displacement Test: This test is useful in small effusions. The suprapatellar pouch is evacuated as described above & medial side of the joint is emptied into the other side of the knee by stroking any excess fluid. Now the distended lateral side is pressurized & refilling of the hollow of emptied medial side is observed. c. Fluctuation Test: It is useful in large effusion. In this test thumb & index finger of one hand is placed on both sides of the ligamentum patellae at infrapatellar fossae. Pushing the fluid by the thumb & index finger of the opposite hand placed in suprapatellar pouch region one can elicit cross fluctuation. Swelling Around Knee Joint Generalized swelling Localised swelling e.g. bursa ,meniscal cyst, exostosis Confined to limits Extending beyond the Of synovial cavity limit of the joint & suprapallellar pouch Major Tumor Infections Trauma - Cellulitis e.g. fracture - Muscle abscess - Infection of tibia, femur or jointSynovial Hemarthrosis Pyarthrosis Synovial Space occupyingEffusion thickening lesion in joint e.g. - RA - TB2. Popliteal fullness: It is commonly felt in baker’s cyst.3. Tenderness: Joint line tenderness exacerbated by tibial rotation (stein Mann test) is suggestive of meniscal tear.
    • Tenderness is looked for in the following manner a. First joint line is palpated by flexing the knee & looking for hollows at both sides of patellar ligament which lie over the joint line. b. Look for tenderness at joint line which is common in meniscal tear, collateral ligament & fat pad injuries. c. Look for tenderness at both proximal & distal attachment of collateral ligaments d. Palpate for tenderness at tibial tubercle e. Flex the knee fully & palpate for tenderness over femoral condylesIndex 3.4 Site of tenderness Possible Etiologies Joint line tenderness - Osteoarthritis - Meniscal, ligament & fat pad injuries Tenderness over point - Collateral ligament injury Of attachment of ligament Tibial Tubercle - Posttraumatic avulsion - Osgood schlatter’s disease Femoral Condyle - Osteochondritis dessicans4. Patellofemoral compression test: Patella is pressed against femoral condyle with knee slightly flexed & side-to-side movement of patella done. Tenderness is suggestive of chondromalacia patellae.5. Palpable osteophyte (osteoarthritic knee).6. Local warmthC. Range of motion: 1. Restriction of range of motion may be due to variety of causes 2. Look for presence of patellofemoral crepitus during motion.Range of movement:Extension: Full extension is considered as 0 with preferablyboth knees examined at the same time. Any loss of extension(extension lag) or any block in extension (springy block e.g.bucket handle meniscus or rigid block as in fixed flexiondeformity) is noted as “ The knee lock X of extension”.Hyperextension (extension beyond 0) is noted by lifting theleg while pressing on the patella; preferably compared to theother side. Hyperextension may be seen in:  Patella Alta  Chondromalacia patellae  Ehlers-Danlos syndrome  Recurrent patellar dislocation  Sometimes ligament injuries.
    • Passive extension may be tested by prone hanging test. Here patient lies down in prone position withlower limbs below the knee hanging beyond the edge ofexamination table. The knee is allowed to extend fullypassively & heel height distance of 2 limbs measured. Itgives a good estimate of knee FFD deformities.Flexion: Flexion is measured with goniometer from 0 ofextension. Normal range of motion is 0 -135. Loss offlexion may be due to arthritis or synovial effusion.D. McMurry test: Here with the knee in full flexion, the tibia is rotated internally & externally while the knee is brought slowly into extension, meniscal tear is associated with an audible click during the menoveure. For medial meniscus tear knee is externally rotated & abducted whereas for lateral meniscus knee is internally rotated & adducted. The more posterior is the tear, in more flexed position of the knee sign will become positive.E. Apley’s grinding test: With the patient in prone position & knee flexed to 90 compression is applied along the long axis of the tibia while rotating it on the femur akin to grinding movement. Pain on external rotation suggests medial meniscus tear while on internal rotation it indicates lateral meniscus tear.F. Ligament stability: 1. Varus & valgus stability: This is best demonstrated by applying a medial or lateral knee stress with knee flexed to 15. Anything more than a jog of motion is suggestive of MCL or LCL injury.Testing For Medial Collateral Ligament Injury Test in extension If positive If negative MCL +ACL Injury Test in 30 flexion + ve - ve Only medial collateral No ligament tear Ligament injury 2. Anterior & posterior cruciate ligament:
    • Tests For Ligament Injury:Lachman Test: With the knee flexed to 30 femur is held firmly with one handwhile an anteriorly directed force is applied to the posterior surface of the tibiawith other hand. The degree of anterior excursion as well as end point is noted.False Positive Test: Uncommonly a bucket handle tear of a meniscus may alter the end point with anormal anterior cruciate ligament giving a false positive result.False Negative Test: It may occur if a bucket handle tear of a meniscus is displaced preventinganterior tibial excursion or altering the end point.Anterior Drawar Test: With the patient’s knee flexed to 90, the examiner sits on patient’s foot &applies anterior displacement force on the proximal tibia. Minimum excursion & a firm end pointshould be noted in a negative test.Posterior Drawar Test: It is similar to anterior drawar test but here a posterior displacement force isapplied on the proximal tibia. It is positive mainly in chronic instability.Posterolateral Instability Test: It is similar to posterior drawar test, in addition to posterior force anexternal rotation force is applied to the proximal tibia. Increased external rotation & drop back oftibia is noted if laxity is present.External Rotation Recurvatum Test: Hold the large toe & gradually bring the knee from 10 offlexion to extension. If positive, the knee goes into external rotation & recurvatum. The positive testindicates posterolateral capsular, lateral collateral ligament & posterior cruciate ligament damage.Index 3.5 Ligament Injury Symptomatic Instability - Only medial or lateral collateral ligament laxity Minimal symptoms - Only cruciate injury Moderate instability - Cruciate with collateral ligament injury Severe instabilityPivot Shift Test: Foot is held in mild internal rotation & a valgus force is appliedto the proximal tibia as the knee is brought from a flexed position of 45 toextension. Positive test is present when a transient anterior subluxation of tibia onthe femur is noted with internal rotation. It is suggestive of anterior cruciateinjury. False negative test may be seen in following circumstances:  Holding the leg externally rotated  Failure to apply valgus force
    •  Holding leg maximally internally rotated  Medial ligament injuryReverse Pivot Shift Test: Foot is externally rotated, knee is moved from a flexed to an extendedposition, minimal valgus force is required. As the knee is brought into extension a jump will benoted. This indicates posteriorly tibia suddenly moving into reduced position in the femur. It isindicative of posterolateral instability (i.e. damage to PCL, LCL & biceps)Apley’s Distraction Test: With the patient in prone position in 90 of knee flexion; stabilize histhigh with your knee. A traction force is applied along the long axis of tibia while rotating the leginternally & externally. Pain indicates ligament instability.Apprehension Test: With patient in supine position, patella is displaced laterally. Sudden tightnessof the quadriceps tendon & an apprehension look on the patient’s face is suggestive of a chronictendency towards frequent patella dislocation.Dreyer’s Test: While in the supine position, the patient is instructed to raise his leg without bendingthe knee. If he is unable to do so, the quadriceps tendon is stabilized just above the knee & patient isinstructed to raise his leg again, if he is able to raise his leg the second time, a fracture of patellashould be suspected.G. Muscle strength: Quadriceps & hamstring muscle strength must be noted. Thigh circumference should be measured on both side at a fixed point from the pole of patella.H. Examination of patella: 1 Patellar Alignment: It is tested by asking the patient to stand with the feet together with inner borders of feet parallel to each other & pointing toward the examiner. a. Infacing (squinting) patellae: Here the patellae are angled toward each other with sometimes-associated patellofemoral pain. It is commonly seen in increased femoral anti- version with compensatory increased external tibial rotation. Intoeing b. Outfacing Patellae: These are seen in patients with habitual dislocation/ subluxation of patella as with knee fully extended ,the patellae sublux outwards. 2 Q-Angle: It is the angle between a line from the anterior superior iliac spine to the center of patella and line from center of patella to the tibial tubercle. It is a measurement of overall patellar alignment. It is normally between 14 to 17 (F> M). The foot & hip should be in neutral position while recording. The biomechanics of patellofemoral joint are affected by the length of patellar tendon and Q angle. An increased Q angle increases the risk of patellar subluxation, Q angle is increased in genu valgum, external tibial torsion, increased femoral anteversion, laterally placed tibial tuberosity, tight lateral retinaculum.
    • 3 Tubercle-Sulcus Angle: Patient sits on the end of examination table with the knees flexed to 90. In this position normally patellae are well seated in the trochlear sulcus of the distal femur. One line is drawn from the center of the patella perpendicular to the floor, other line is drawn from center of patella to center of tibial tubercle. The angle sustained should be between 5 to 8 (F>M). Increase in angle is suggestive of lateral displacement of tibial tubercle. 4 Patellar Height: Patellar alta is the term used for high riding patella whereas patella baja (patella infra) is a low riding patella. Patella alta may be seen acutely in patellar tendon rupture. Patellar baja may result due to trauma or surgery. Clinically this is tested with the patient sitting at the edge of the table with knee flexed to 90. In a normal patient, the patellae should face directly forward in this position. In high riding patellae, patellae faces upward towards the ceiling, patellae baja is detected by clinically correlating height of both patellae. 5. Perkin’s Sign: Patella is displaced on one side (medial or lateral); palpate for presence of peripheral tenderness. It is positive in chondromalacia. 6. Fouchet’s Sign: Also known as patellar grind test. 7. Clarke’s Sign: Patient lies in supine position with knee extended, examiner pushes the patella by his hand in a downward direction & patient is asked to contract the quadriceps. Chondromalacia is associated with retro patellar pain.I. EXAMINATION IN PRONE POSITION: It includes examination for presence of any swelling in popliteal fossa, any bursa at muscle attachment or any tenderness due to trauma.J. SPECIAL TESTS: 1 Test For Osteochondritis Dessicans: It can be vaguely tested by looking for local tenderness on the surface of the femoral condyle with knee flexed. 2 Wilson Test: This test is useful for osteochondritis of medial femoral condyle. Here the knee is flexed to 90, internally rotated & then it is gradually extended. When the raw area comes into contact, patient will complain of pain which gets relieved with external rotation of knee.K. OTHER EXAMINATION: This include examination of:  Ipsilateral hip  Contralateral knee  Neurovascular structures of the limb.3.4 COMMON CAUSES OF ANTERIOR KNEE PAIN:1. Patellofemoral overload2. Misuse of knee3. ‘Jump’ Knee4. Patellofemoral malaligament5. ? Bipartite patella6. Patellar cyst or tumours7. Plica syndrome8. Prepatellar bursitis9. Osteochondritis dissecans10. Discoid meniscus11. Torn meniscus12. Fat pad syndrome13. Sinding-Larsen-Johansson syndrome
    • 14. Post surgical neuroma15. Pes Anserinus bursitis16. Referred /radiating pain from hip, spineIndex 3.6 Difference Between Arthritis & Arthralgia Arthritis Arthralgia 1. Both subjective & objective - Only subjective complaints Signs are present - No objective signs present 2. Signs of inflammation such - No signs of inflammation as pain, edema, tenderness present 3. It may be due to local or - It is a sign of generalized disease. Systemic diseaseFlowchart 3.1: Anterior knee pain History /Examination (change in activity levels, Swelling, increase in quadriceps angle, crepitus) Objective findings Chondromalacia Prepatellar bursitis Patellar tenderness Anterior joint line & tenderness Patellar tracking patellar tendinitis X-rays disorder Treat accordingly Yes Stress fracture Negative Meniscal No other Tumour, infection signs +ve meniscal Quadriceps programme Activity signs Improvement modification Arthroscopy Continue & No improvement Observe Improvement No improvement observe Bone scansContinue program Patellar realignment& modify activity stress fracture Splint, modify activity3.5 CHRONICALLY SWOLLEN KNEEPainful knee1. Traumatic a. Torn Meniscus b. Ligament laxity c. Traumatic Synovitis2. Recurrent Dislocation of Patella3. Chronic Arthritis: a. Chronic Septic Arthritis b. Tuberculosis arthritis c. Reactive Arthritis & other seronegative spondyloarthropathy d. Rheumatoid arthritis e. Osteoarthritis
    • f. Haemophilic Joint4. Loose Bodies in Knee jointPainless Knee:1 Charcot’s joint.2 SyphilisFlowchart 3.2: Chronic Knee Swelling Cold Other Findings Hot (Patellofemoral malalignment, snapping tendon, IDK knee) X-Rays Aspirate Normal Bony degeneration Inflammatory Septic Sympathetic - OA (Infective) - Loose Bodies Aspiration Synovial biopsy Aspirations Treat Underlying pathology Antibiotics - Treat Underlying Arthrotomy conditionImprovement improvement - SOS synoviectomy Treat underlying cause +ve - vePhysical Therapy Diagnostic Arthroscopy3.6 CYSTIC SWELLINGS AROUND KNEEAnteriorly: a. Suprapatellar Bursa: Superior extension of synovium beneath the quadriceps tendon b. Prepatellar Bursa (Housemaid’s Knee): It lies beneath the skin in front of patella c. Intrapatellar Bursa (Clergyman’s Knee): Lies in between the ligamentum patellae & anterior surface of tibia. It may be superficial or deep.Laterally:a. Biceps Bursa: Lies between biceps tendon & fibular collateral ligament.b. Posterolateral Bursa: I. Between popliteus tendon & fibular collateral ligament II. Between popliteus tendon & lateral condyle of femurMedially: a. Bursa between medial head of gastrocnemius & capsule of the joint b. Cyst of medial meniscus
    • c. Pes anserinus bursaPosteriorly: a. Morant Baker’s cyst: It is a midline herniation of the synovial cavity of the knee secondary to persistent effusion in the knee. b. Semimembranosus Bursa (Commonest): It lies postero-medially between the medial head of gastrocnemius & the musculotendinous mass of semimembranosus c. Popliteal aneurysm must be differentiated from morant baker’s cyst.Morrant Baker’s Cyst: It is a popliteal cyst which was firstdescribed by Adam in the year 1840 & later by baker in 1877.Site: The distended bursa may arise between.1 Hamstring & collateral ligaments2 Hamstring & tibial condyles3 Each head of gastrocnemiusEtiology:1 Herniation of synovial membrane through posterior part of capsule OR2 Escape of fluid via the normal communication of either semimembranosus or medial gastrocnemius bursa with knee.Types:1 Cyst In Children: Here the intra-articular pathology is rare with no communication of cyst with the joint capsule. Recurrence rate is very low & postoperative immobilization is not required.2 Cyst In Adults: Intra-articular pathology is seen in 50% of cases with cyst usually communicating with capsule, because of intracapsular extension recurrence is common & postoperative immobilization is required.3 Giant Cyst: It is a huge popliteal cyst seen in rheumatoid arthritis. It is excised in 2 stages: Cyst excision in first stage followed by synoviectomy later.Clinical Features In Adults:  Usually in middle aged patients  Pain on walking along with tenderness  Swelling situally usually near the midline of popliteal fossa  Cystic in nature  Fluctuation +ve.  Knee movements are usually painful & restricted with synovial effusion + ve.  X-Rays may show degeneration or inflammatory arthritic changes.Differential Diagnosis of Popliteal Mass:1 Synovial cysts2 Baker’s cyst3 Arterial or venous aneuysms (Expansile pulsatile swelling)
    • 4 Thrombophlebitis5 Cysts of artery6 Pigmented villonodular synovitis7 Synovial haemangioma8 RhabdomyosarcomaTreatment:1 The cyst in children tends to disappear by 7 years of age & hence excision should be avoided by this age.2 Aspiration followed by crepe bandage3 If it fails, complete excision of bursa by a transverse incision & closure of the capsular orifice by a. Scarrification of edges & suturing b. By using tendon graft from gastrocnemius4 Treatment of associated joint pathology if any e.g. rheumatoid or osteoarthritisPrepatellar Bursa :- It is a superficial bursa present between skin and patella containing minimal fluid. It usually does not communicate with the knee joint.Pathophysiology :- This synoviumlined structure separates the patella from the patellar tendon and skin. Its main function is to reduce friction and allow maximal range of motion. Inflammation of bursa is known as prepatellar bursitis.Incidence :- Bursitis is mere common in males and can occur at any age. In pediatric age group and immunocomposed host it is likely to be infective.Clinical presentation :- - Knee pain - swelling or redness of the knee. - inability to kneel on the affected side. - difficulty in walking. - history suggestive of possible etiology such as excessive kneeling, history of trauma or repetitive motion.Physical findings :- - Tenderness and erythema over the patella. - fluctuant swelling over the lower pole of patella. - reduced knee motion due to pain at terminal range.Etiology :- It includes : - direct trauma. - repetitive overuse (i.e. kneeling) - infective process (should be differentiated from septic arthritis where joint motion is extremely painful and restricted and where popliteal fossa fullness and tenderness can be felt). - crystalline arthropathy. - inflammatory rheumatic diseases. - occupational predisposition : especially in homemaker (housemaid knee), plumber, coal miner etc.Differential Diagnosis :- Must be differentiated from other causes of anterior knee pain, cellulites and connective tissue disorders.Investigations :- These include X-rays (to rule out other pathologies) and aspiration of fluid for biochemistry and microbiological analysis. Rarely MRI may be required in difficult cases. Aspirated fluid may show presence of pus cells, bacteria and crystals of crystalline arthropathies.Treatment :- Prepatellar Bursitis
    • Conservative treatment (rest, ice, NSAID, avoidance of kneeling, use of knee pads) Successful Failure Continue Aspirate Non infective Septic Steroid injection incision and Drainage Responsive Unresponsive Continue conservative Surgical Excision of bursa.3.7 DEFORMITIES AROUND KNEE JOINT:A. Genu Valgum (Knock-Knee) & Genu Varum (Bow-Leg): Normally the children are born with a varus tibia-femoral angle which decreases with age. By 18-24 months of age, the knee becomes straight. At the age of 3-5 years, valgus angulation becomes more pronounced from then to the attainment of maturity there is a valgus normal angulation of knee around 5- 10. In genu valgus the knee is angled inwards, the tibia being abducted in relation to the femur. The two malleoli are away from each other, the distance between the two is indicator of severity of genu valgus. In genu varum the knee & leg are bowed inwards with & femoral condyles away from each other. The deformity can be measured by measuring the distance between two medial femoral condyles.Genu Varum: It is lateral angulation of knee with medial deviation of long axis of femur & tibiaClassification:A. Depending upon bone involvement  Tibial  Femoral  CombinedB. Depending upon number of knee involved  Unilateral
    •  Bilateral Types Unilateral Bilateral a. Traumatic (Affecting growth epiphysis) b. Infective (E.g. osteomyelitis) c. Neoplastic d. Growth abnormalities Physiological Pathological (Should get corrected by 4 years) Common Uncommon  Congenital Bilateral trauma,  Developmental Neoplastic or  Metabolic Infective involvement  Endocrine  Degenerative  Inflammatory  Occupational  Idiopathic  Paget’s Disease  Blount’s DiseaseAssociated Deformities:1 Intoeing of both feet2 Internal rotation (torsion) of distal tibia3 Patella faces outward during stance phase4 Associated laxity of lateral structures of knee5 Contracture of medial structures of kneeExamination In Genu vara:1 Degree of varus & tibial torsion should be especially measured & recorded Both ankles of child are held together & the distance between the knee is measured2 Knee motion & ligamentous instability should also be assessed.3 Plum line Test: A line drawn from ASIS through the center of patella passes normally through medial malleoulus. In genu varum medial malleoulus is medial to the line.Differential Diagnosis of Genu Varum:1 Bow Leg: This is deformity at leg with an inward concavity of tibia, the knee joint is not deformed. It can be detected by dropping a plumb line from the midinguinal paint. Unlike in genu varum where the knee lies outside to the joint, the knee of bow leg lies at the center of the line.Causes of Bow Leg: a. Physiological of infancy b. Idiopathic c. Posttraumatic d. Congenital e. Syphilitic tibia f. Paget’s disease g. Pseudoarthritis of tibia h. Osteogenesis imperfecta i. Dyschondroplasia
    • 2. Anteversion of femoral neck may lead to apparent genu varum.Genu Valgum (Knock Knee):Definition: Outward deviation of longitudinal axis of both tibia & femur with apex at knee directedmedially is known as genu valgum.Classification: Types Physiological Pathological Unilateral BilateralEtiology:Unilateral Deformities:1 Traumatic2 Neoplastic3 Infective lesionsBilateral Deformities:1 Congenital2 Idiopathic (commonest)3 Endocrine disorders (e.g. thyroid disorders)4 Rickets5 Epiphyseal dysphasia6 Inflammatory disorders (e.g. RA)7 Paralytic disorders8 Degenerative disease.Concomitant Deformities1 Lateral rotation of lower end of femur & upper end of tibia by pull of biceps & tensor fascia lata.2 Medial rotation of lower end of tibia3 Lateral dislocation of patella4 Shortening of lateral structures & elongation of medial structures of knee5 The gait pattern is marked by circumduction6 Pronated flat foot may be present.Clinical Examination:1 The extent of valgus deformity is noted by measuring the intermalleolar distance with both knee touching each other & patella facing upward (>10 cm is abnormal)2 Tibial torsion, should be looked for.3 Ligament laxity if any is noted4 Range of motion is tested5 If deformity lies in the lower end of femur, it will disappear with flexion of knee whereas it will persist in upper tibial pathology.6 If a plumb line is drawn from ASIS to center of patella, the medial malleolus will lie outside the line, normally the line passes through medial malleolus.Indications For Treatment In Genu Vara/ Genu Valga:1 Presence of bowleg or knock-knee outside the age range (i.e. bowleg beyond age 3 & knock-knee beyond age 7)2 If it is unilateral3 The intercondylar or intermalleolar distance of more than 2 inches4 If the intercondylar or intermalleolar distance is rapidly progressing by more than ½ inch within 6 months.
    • 5 Associated symptoms like pain or limp or sign of rickets or Blount’s disease or other disease syndromes.Treatment: Treatment Protocol < 6 years of age > 6 years of age Observation Before attainment of maturity After maturity - Stapling of epiphyseal Corrective Osteotomy Convex side of deformity - Epiphyseodesis: excision & fusion of epiphyses on convex side of deformityGenu Recurvatum: It involves hyperextension at the knee joint.It may be:1. Congenital2. Acquired : a. Polio b. Charcot’s joint c. Ligament Laxity (Marfan’s syndrome) d. Mal-united Fracture e. Epiphyseal growth defectsTreatment:  Supportive Brace  Corrective Osteotomy3.8 CLICKING OF KNEE JOINT: 1. Snapping of iliotibial band across a bony spur 2. Snapping of medial hamstring. 3. Loose bodies in the joint 4. Meniscal tear 5. Patellofemoral malalignment3.9 MEDIAL JOINT LINE PAIN:Commonest causes are: 1. Patellofemoral malalignment 2. Medial compartmental OA 3. Meniscal tear/degeneration 4. Medial collateral ligament tear.3.10 LATERAL JOINT LINE PAIN: 1. Loose body 2. Meniscal cyst 3. Torn lateral meniscus usually associated with anterolateral rotatory instability. 4. Iliotibial band syndrome caused due to friction with lateral femoral condyle 5. Lateral compartment DJD (Rare secondary to long standing valgus malalignment at knee or due to avascular necrosis).
    • 3.11 TUBERCULOSIS OF THE KNEEThe knee joint is the third commonest site for osteoarticular tuberculosis & forms approximately10% all skeletal TB.Pathology: 2 Types Osseous Tuberculosis Synovial tuberculosis (Start in femoral or (starts in synovium) tibial condyle or rarely patella) Tuberculous Granulation tissue formation Erosion of articular cartilage, cruciate ligament, periarticular tissues, capsules & ligament Articular Fibrous ankylosis Triple deformity: flexion cartilage fraying due to filling up of of joint with posterior of joint by granulation subluxation, lateral tissue subluxation & lateral rotation, abduction of tibiaPrognosis: It depends upon stage of disease Stage of synovitis stage of early stage of advanced treatment arthritis: treatment arthritis: treatment Excellent ROM Good ROM Arthrodesis in functional good prognosisfair prognosis position
    • Clinical Features:  Symptoms: Gradual onset  Younger age group usually 10-25 yrs  Pain & swelling  In later stages stiffness & deformitySigns:A. Swelling: due to a. Synovial hypertophy b. Synovial effusionB Muscle atrophy: usually due to diseaseC. Regional lymphadenopathyD. Deformity: a. Flexion I. Due to synovial effusion II. Muscle spasm. b. Triple displacement due to ligament laxity.E. Cold abscesses & sinus formation.F. Movements: Earlier restriction is due to muscle spasm, later restriction is due to secondary arthritis.Radiographic Changes: Typical radiographic changes as noted in osteoarticular TB can beobserved.Differential Diagnosis: Other Mono-Articular affections must be differentiated e.g. - Rheumatic arthritis (in children) - Chronic traumatic synovitis as in Internal Derangement of knee  Rheumatoid arthritis  Subacute pyogenic arthritis  Haemoarthrosis  Dysenteric arthritis  Villonodular synovitis  Synovial chondromatosis  Synovioma  Haematoma.Treatment:Aim: To achieve, whenever possible, a painless mobile jointMethods: Methods Conservative Surgical - Medication - Splintage - Physiotherapy
    • Diagnostic Curative Arthroscopic/ open - Synoviectomy Synovial Biopsy - Joint Synovial Aspiration debridement - ArthrodesisTreatment plan for TB Knee: T.B. knee Stage I & II Stage 3 & 4 Traction + AKT Traction + AKT Mobilization Reasonable Reasonable joint possible joint not Possible Pop immobilization surgical arthrodesis Fibrous AnkylosisIndividual Techniques:A. Synoviectomy: it can be done by 2 methods a. Open synoviectomy b. Arthroscopic synoviectomyIndications: a. Plain synoviectomy in stage I knee TB. b. Synoviectomy & joint debridement in stage 2 knee TB.B. Joint debridement: Done in stage 2 knee TB whereby pus is drained, synovium tissue excised,cavities curetted.C. Arthrodesis: Done in functional position of 5-10 of flexion & neutral rotation in stage 3 arthritisnot responding to conservative treatment.Methods used: 1. Charnleys compression arthrodesis 2. Intramedullary nail from femur to tibia. 3. Ilizarov apparatus. 4. Internal fixation using plates or steinmann crossed pins.3.12 INTERNAL DERANGEMENT OF KNEE JOINT (I.D.K)The term internal derangement originally coined by William Hey (1784) is loosely used to describethe abnormalities in the knee functions due to any cause, but mostly traumatic.These include the following:Articular Proper Lesion:1. Bony Lesion a. Sliced fracture of articular cartilage. b. Epiphyseal fracture
    • c. Condylar fracture - Tibial - Femoral d. Tibial spine fracture or avulsion e. Bony loose bodies f. Chondromalacia patellae g. Osteochondritis dessicans h. Chondrocalcinosis i. Osgood schlatter’s disease j. Pellegrini steida’s disease k. Sinding -Larsen- Johansson’s disease l. Traction osteochondritis of lower pole of patella m. Recurrent subluxation / dislocation of patellaSoft Tissue Lesion: a. Meniscal Lesions: tear, cyst, discoid meniscus b. Cruciate tear or avulsion: ACL or PCL injuries c. Synovial folds entrapment d. Nipping of intrapatellar pad of fat; hoffas disease e. Loose bodies: fibrous loose bodies - Cartilaginous loose bodies - Synovial chondrocalcinosisWalls Of The Joint:  Lesions of the capsule with its reinforcing ligaments  Avulsion or rupture of  Collateral ligament  Oblique ligament  Quadriceps expansion  Accurate ligaments.Quadriceps Apparatus Lesions:  Quadriceps tendon rupture  Fracture of patella  Avulsion or rupture of ligamentum patella  Avulsion/ fracture of tibial tuberosityClinical Presentation Of IDK: These include 1. History of trauma (usually twisting or rotational) 2. Immediate pain 3. Swelling 4. Slight flexion of knee 5. Inability or disability in bearing weight 6. History of locking or giving away (instability) 7. Other associated features of etiological condition.Investigations in suspected IDK: a. Arthroscopy b. Arthrography: It is gradually being displaced by arthroscopy c. Examination under anesthesia: It is specially useful in tense swellings & painful muscle spasms. d. Provocative Exercises: Specially useful in doubtful meniscal lesions. It is aimed at stressing the menisci by applying torsional stress to the weight-bearing knee. In damaged meniscus, the exercise is followed by localized pain, swelling & sometimes locking.3.13 OSGOOD SCHLATTER DISEASE:
    • It is a painful disabling swelling about the tibial tubercle occurring in adolescents.Etiology  Repeated trauma  Friction  Children about the rapid growth period of puberty particularly boys are predisposed  It may be bilateralPathology: Partial separation or failure of fusion of tubercle- epiphysis With the main epiphysis may occur due to trauma Obliteration of blood supply Aseptic necrosisTypical pathological changes of osteochondritis can be seenClinical Picture: Patient presents with pain, tenderness and soft tissue swelling withoutinflammatory signs at tibial tubercle, kneeling is painful. Active extension of knee against resistanceis painful. The symptoms usually subside at 15 yrs of age when the apophysis fuses to the main bone.X-Rays Findings: The tibial tubercle consists of multiple fragmented appearing areas of ossificationthat are dense in contrast to underlying osteoporotic area in the main bone. The soft tissue anterior tothe tubercle are swollen.D/D: In complete avulsion of the tubercle, the ossification center is displaced upward.Treatment:Conservative: Ice packs NSAIDS Ultrasonic therapy Pop cylindrical cast immobilizationSurgical: Surgical Options Local steroid Multiple drill Bone peg injection holes technique inserted thro the tubercle Surgical excision of persisting Fragment (must be avoided to prevent Premature epiphyseal plate closure)Treatment Protocol: Pain in tibial tubercle area with focal tenderness in adolescent X-rays –AP & lateral projections To rule out other bony lesion (e.g. osteosarcoma, soft tissue lesion, tuberosity avulsion) OSGOOD SCHLATTER DISEASE
    • Mild enlargement Moderate enlargement Marked enlargement Few symptoms Moderate symptoms severe symptoms Reassurance; resume Restriction of activities, Restrict activities, knee normal activities knee immobiliser cast, NSAIDS immobiliser cast , NSAIDS, USG therapy Symptoms persist Local wycort injection Symptoms resolves Resume normal activities Symptoms persist Surgery3.14 LOOSE BODIES IN THE KNEE JOINT:Loose bodies are common presentations in the joints especially the knee joint.Types:  Fibrous loose bodies  Cartilaginous loose bodies  Bony/ osseous loose bodiesEtiology:A. Non Traumatic 1. Osteoarthritis with detached osteophytes 2. Osteochondritis dessicans 3. Synovial chondromatosis 4. Tuberculous arthritis 5. Rheumatoid arthritis 6. HaemophiliaB. Traumatic: 1. Organised hoemarthrosis 2. Organised, snapped synovial fringes 3. Loose fragments of intraarticular fracture 4. Avulsion of articular cartilage 5. Foreign bodies 6. portions of menisciClinical Presentations:  Locking in the joint which may get corrected automatically & is followed by synovial effusion  Some times loose body can be felt in the joint.X-rays: Most loose bodies are radio opaque & can be detected by plain x-rays, fibrous loose bodiesrequire arthroscopic diagnosis.Treatment: Treatment Surgical removal Open surgical Removal Arthroscopic surgical removal
    • Complications: It left unattended, can lead to damage to the articular surfaces.3.15 CHONDROMALACIA PATELLA:It is characterized by blistering, fibrillation & cystic change in patellar cartilage mainly involvingmedial facet. It is caused by patellofemoral malalignment which may be due to weak vastus medialis,increase ‘Q’ angle, foot abnormalities, genu valgus etc.Clinical Features: Anterior knee pain exacerbated on descending down the staircase or while sittingfor a prolonged period (as in cinema hall). Features of chronic synovitis & patellofemoralmalalignment are present. On grinding the patella on femur while flexing the knee pain is produced,tenderness can also be felt clinically on undersurface of patella.Stages:1 Swelling and softening of the cartilage2 Fissuring within the softened areas.3 Fasciculation of articular cartilage almost to the level of subchondral bone4 Destruction of cartilage with subchondral bone exposedX-ray Findings: It is better seen in slightly oroverexposed lateral x-ray. Axillary radiographhelps in determining facet involvement.Commonly medial facet involved.Treatment: Rest, activity modification,physical therapy, realignment of maltracking ofpatella using orthotics & arthroscopic shaving ofundersurface of patella.3.16 RECURRENT DISLOCATION OF PATELLA:This condition usually occurs following an acute traumatic dislocation of patella which has nothealed properly after an initial injury. The dislocation occurs usually to the lateral side & must bedifferentiated from habitual dislocation of patella in which dislocation occurs in each flexion &extension movements of the knee.The predisposing factors include:A. Bony Defects 1. Patella alta 2. Genu valgum 3. Hypoplastic lateral condyle of the femur 4. Femoral anterversion 5. Hypoplastic patella 6. Genu recurvatumB. Soft Tissue abnormalities 1. Tight lateral retinaculum 2. Lax medial retinaculum 3. Abnormal insertion of vastus medialis 4. Lateral insertion of patellar tendon 5. Atrophy of vastus medialis 6. Hypertrophy of vastus lateralis 7. Generalised joint laxityTreatment: The results of conservativetreatment is poor, surgery being the treatment ofchoice.3.17 FRACTURES OF PATELLA:CLASSIFICATION
    • 3.18 UNCOMMON CAUSES OF KNEE PAIN: A. Bipartite patella: It is a common Incidental x-ray finding. If the superolateral fragment is mobile it can give rise to pain & tenderness at the junction of two fragments. If pain is severe, excision of extra fragment is done for getting therapeutic relief. B. Excessive lateral pressure syndrome: Caused due to tightness of lateral retinaculum, patient presents with pain on superolateral aspect of patella & retropatellar tenderness. Arthroscopy shows a normal patella. Pain relief is best obtained by lateral retinacular release done either arthroscopically or by open release. C. Fat Pad Syndrome: Retro patellar tendon pain & tenderness may be caused by fat pad getting caught in tibia-femoral joint. Relief is obtained by rest, NSAIDS & heat therapy. D. Ilio-Tibial Tract Syndrome: Due to repeated rubbing of ilio-tibial tract on the lateral femoral condyle, synovium deep to ilio-tibial tract gets inflamed & is painful. Treatment consists of rest, NSAIDS or steroid injection. E. Patellar tendinitis: Commonly found in sport players, the tendon may get partially torn or inflamed at its insertion to patella (Jumpers knee). Treatment comprise of rest, NSAIDS / or steroid injection. Sports Related Leg Problems: A. Shin splint: It is characterized by pain along the medial distal third of tibial shaft caused due to overuse of tibials anterior or posterior muscle unit. Patient presents with aching pain after running with tenderness along the involved muscle unit. Treatment comprise of rest, NSAIDS & contrast baths. Prevention involves warm up, conditioning & stretching program, avoidance of hard surfaces & SOS orthotic devises to prevent foot from hyperpronation. B. Stress Fracture: It mainly involves proximal posteromedial tibia & distal fibula. C. Exertional Syndrome (Chronic compartment syndrome): It is caused by a transient rise in compartmental pressure involving anterior or lateral muscular compartment of the leg as a result of exercise. Patient presents with increasing pain in the anterior or lateral aspect of the leg with different levels of exercises. Numbness & paraesthesia in the foot may be present. Diagnosis is confirmed by recording compartmental pressure in excess of 30 mm Hg or a relative increase in pressure by at least 20 mm Hg after exercise. Treatment involves rest, orthotics, stretching exercises. In non responsive cases fasciotomy (decompressions) of the compartment may be required.Common causes of leg pain:In children:  Osteitis or other infection  NeoplasmAdolescent:  Neoplasm (osteod osteoma, osteoblastoma, osteosarcoma)Young Adults:  Stress fracture  Infection (brodie’s abscess)  Anterior compartment syndrome  Shin splintsAdults:  PID & LCS  Vascular deficiency  Paget’s disease  Syphilis  Neoplasm  Foot disorders  Ruptured plantaris tendon
    •  Thrombophlebitis & DVT3.19 LOCKING OF KNEE JOINT:It is described as inability to complete the last few degrees of extension due to soft tissue or bonyblock. Locking of the knee Springy block Rigid block Meniscal tear - Loose bodies - Fixed flexion deformity3.20 CAUSES OF HEMARTHROSIS:1. Trauma:  Injury with or without fracture  Iatrogenic2. Tumors:  Pigmented villonodular synovitis  Haemangioma  Secondary metastasis3. Bleeding disorder:  Haemophilia type A, B & C  Certain drugs such as thrombolytic therapy4. Connective tissue disorders:  Pseudoxanthoma elasticum  Pigmented villonodular synovitis5. Miscellaneous:  Scurvy  Acute septic arthritis  Charcot’s joint  Goucher’s disease  AV fistula or ruptured aneurysm  Haemoglobinopathies (i.e. sickle cell disease)Clinical Presentation of Haemophilic Knee:  Family history  Previous such episodes  Patient pale, history of bleeding from other sides will be available  History of prolonged bleeding after any cut.  Patient have swollen, warm knee with flexion deformity  Advanced cases may have varus/ valgus deformity & sometimes ankylosis  No lymphadenopathy noted.3.21 STIFFNESS IN THE JOINT:Limitation of movements can be a. In all directions - Due to arthritis b. Not in all directions - Due to synovitis &/or spasm of muscle
    • c. Fixed movement in - Due to fixed deformity one or more directionsIndex 3.7 Types of joint stiffness: Extraarticular Intraarticular 1 Biological factors like scar adhesion No obvious scar adhesion, sinus Sinus or contracted tissue can be seen or contracted tissue can be seen. 2 Joint line tenderness is usually absent Present 3 Whatever range of motion possible is Possible movements are usually usually painless painful 4 X-Rays are usually normal Joint space is reduced, joint margins fluffy,osteoporosis is usually present. Evidence of Underlying pathology may be present. 5 Extraarticular release improves the Extraarticular release usually not the movements dramatically helpful 6 Manipulation under anesthesia does not It may help. Improve range Knee joint stiffness Clinical examination Mechanical block No evident mechanical block Flexion Extension pain absent pain causing ROM contracture contracture Exercises Exercises Non-inflammatory inflammatory ? internal derangement Effective Ineffective - Medication Continue serial casting Arthroscopy - physical therapy Effective Not effective Physical therapy Resume Arthrolysis if no relief Exercises including Release of Posterior capsule Recent onset Long duration & hamstrings Manipulation Quadricepsplasty No relief
    • Effective Exercise3.22 CLINICAL PRESENTATION OF MENISCUS TEAR:Patient usually presents with history of rotational injury in weight bearing & partially flexed knee.There is history of immediate pain, mild swelling & inability to extend the knee immediately. Fullpassive ROM is possible, terminal active flexion is painful. McMurry test or Apley’s grinding test ispositive. Maximum tenderness is noted in the joint line approximately at the middle of medialcompartment.3.23 CLINICAL PRESENTATION OF GCT AROUND KNEE:It may involve upper end of tibia or lowest end of femur in 3rd decade. It is an eccentric, tenderswelling which may yield on pressure (egg shell crackling) with knee joint motion preserved for longtime. Diagnosis is confirmed radiologically & by biopsy.3.24 COMMON TUMOR/ TUMOR LIKE LESIONS:A. Benign tumor-like lesion involving joints: 1 Pigmented villonodular synovitis 2 Synovial osteochondromatosis 3 Chondroma: It is an isolated cartilaginous mass mainly involving knee 4 Osteoid osteoma 5 Lipoma may involve joint capsule or synovium 6 Hemangiomas are characterized by recurrent episodes of hemarthrosis mainly involving knee joints of children & young adults.B. Malignant Tumors: 1 Synovial sarcoma 2 Synovial osteochondrosarcoma 3 Metastatic carcinoma (commonly from lung or breast cancer) 4 Lymphoma/ myeloma 5 Leukemic infiltration 6 Contiguous spread of adjacent bone sarcoma3.25 IMPORTANT TERMINOLOGIES RELATED TO SPORTS INJURIESSwimmer’s Knee: Knee pain occurring due to medial collateral ligament stress caused due to valgusstress placed on the knee while swimming the breast strokeJumper’s Knee: patellar tendinitis occurring due to repetitive stresses in high jumpers & volleyballor basketball player results in pain at the inferior pole of patella at its attachment to the patellartendon known as jumpers kneeRunners Knee (Patellofemoral Syndrome): Pain occurring in runners due to compression of nervefibers in the subchondral bone of the patella or from a synovitisSinding Larsen – Johansson Disease: It is caused by persistent traction at the cartilaginous junctionof patella & patellar ligament at inferior patellar pole leading to anterior knee pain with activity inadolescent boys.Clinically one can feel tenderness at inferior pole of patella with x-rays sometimes showing varyingamount of calcification or ossification at the junction. There is sclerosis, decalcification &fragmentation of inferior pole of patellaD/D: It includes1 Pediatric patella avulsion fracture2 Patellar stress fracture3 Bipartite patella4 Osgood schlatter’s disease5 Jumpers knee (which is a degeneration of patellar tendon).
    • Treatment: It includes rest, ice therapy, USG therapy, NSAIDS, quadriceps strengthening exercises,SOS immobilisationPellegrini - Steida’s Disease: It is caused by incomplete rupture of the medial collateral ligament atits femoral attachment followed by calcification. It results in localised pain & tenderness in theregion.3.26 ARTHROSCOPY OF KNEE JOINT:Arthroscopy refers to visualization of interior of a joint. “Endoscopy” means to see within referringto a body cavityCommon Sites Where Commonly Arthroscopy Is Done:  Knee  Ankle  Shoulder  Hip JointInstrument (The Arthroscope): It consists of a trocarthrough which a telescope is inserted into the joint. Atthe external end the telescope terminates in an eyepiece;at the internal end in an electrical light bulb, back ofwhich is the lens. The trocar is equipped with two stop-cocks for distension & irrigation of the joint.Arthroscope Obliquity: This depends upon angle ofthe end of the optical tube of the arthroscopic to thetube. This angle is normally 25-30 & it alters the fieldof view by that many degrees from the axis of the optical tube.Functions Of An Arthroscope:1 Sweeping: Side to side or up & down movement to see objects or anatomic areas.2 Pistoning: Moving the tip of the arthroscope closer to an object to magnify it & decrease the field of vision, or moving away from an object to decrease the magnification but increase the field of vision.3 Rotation: Turning the arthroscope about a 360 are because the tip of arthroscope is usually angled, this rotation increases the field of view due to the obliquity of the tip cut.4 Triangulation: using sweeping, pistoning & rotation to place an object in the direct field of vision of the arthroscope through an adjacent portal.Portal: Portals are small cut down incisions placed to access specific anatomic areas & avoid vitalstructures.Basics Steps Of Arthroscopy:1 Anesthesia: Routinely spinal preferred, but sometimes general or local anesthesia can be used.2 Skin incision & opening of the capsule using stab knife3 Insertion of trocar4 Collection of synovial fluid5 Irrigation of joint to achieve distension6 Introduction of the telescope7 Inspection of the joint in a systemic manner.8 Removal of specimen for pathological examination9 Flushing of joint & closure of the woundIndications for knee Aarthroscopy :-
    • 1. Injuries : ALC tear, meniscal tear, cartilage injuries.2. Recurrent effusions.3. Locking of joint.4. Chronic synovitis.5. Haemarthrosis : for evacuation of blood and diagnosis of possible etiology.6. Knee pain of unknown cause.Advantage of Athroscopic surgery :-1. Very low morbidity and complication rate.2. Can be done as an outpatient procedure or short indoor procedure.3. Cosmetically excellent.4. Short recovery time.5. No disturbance of any sensory supply.6. Associated injuries may also be treated.7. Hard to reach regions such as posterior horn of meniscus may be visualized.Complications of Arthroscopy:1 Infection.2 Vascular or nerve injury: Nerve injury is mainly due to prolonged tourniquet time.3 Chronic persistent synovitis.4 Haemarthrosis.5 Persistent drainage with synovial fistula.6 Deep venous thrombosis.3.27 OSETOCHONDRITIS DESSICANS :-This localized condition affects articular surface involving separation of cartilage and subchondralbone.Etiology :- There are various theories proposed :1. Ischaemia2. Trauma.3. Abnormalities of epiphyseal ossification.4. Metabolic factor.5. Hereditary factor.6. Anatomical variation.Incidence :- More common in males ( M : F  3:1). Bilateral occurrence is around 30 percent. Itis most commonly seen in adolescents.Clinical features :- Anterior knee pain. Features of loose bodies in joints.History :-- A vague pain with history of clicking or popping.- Swelling and stiffness may be present.- Symptoms may be associated with activities.- Features of locking may occur due to loose bodies.- Long standing cases may have features of arthritis.- Giving away may occur secondary to weakness of quadriceps mass..Examination :-- Synovial effusion.- Quadriceps wasting.- Joint line tenderness.- Restricted range of motion.- Palpable loose bodies.- Positive Wilson’s test.Investigations :- These include X-rays / MRI. Bone scans are useful in monitoring healingprocess.Differential Diagnosis :- Other causes of anterior knee pain must be ruled out.
    • 1. Osteoarthritis.2. Chondral fracture.3. Meniscal tear.4. Synovial osteochondromatosis.Grading of Lesion :-Grade 1 : Detected on X-ray with articular surface intact.Grade 2 : On arthroscopy articular injury seen.Grade 3 : Lesion separates from rest of the bone.Grade 4 : Loose fragment within joint.Treatment :- Severity of loose bodyGrade I and II Grade III Grade IV3 – 6 months of non operative Pinning Drilling of defect for revascularisationtrial using restricted motion screw fixation pinningand axillary crutches. Screw fixation excision of loose fragments osteochondral autograft transplantation3.28 RADIOGRAPHIC EXAMINATION OF KNEE JOINT:It includes AP, lateral, axilla view & tunnel view in skeletally immature patient.AP View: This view is taken with patient in supine position, knee extended & leg in neutral position.Central beam should be directed vertically with 5 to 7 cephalic tilt.One can visualize:  Femoral/ tibial angle  Medial & lateral compartment space  Size, position & integrity of patellaAxilla View of the knee: It profiles the patellofemoral joint, one can visualize patellar tilt, patellarsubluxation & sulcus angle.Method: These x-rays are taken of both knees together (for comparison) in a knee flexion between20 to 45.Any flexion more than 45 will mask patellofemoral anamolies.Types:Laurin Technique: The axial view taken in 20 of flexion is used to measure lateral patellofemoralangle which gives an idea of an abnormal tilt. The angle formed by lateral patellar facet & line drawnacross most prominent aspect of anterior portion of femoral trochlea normally opens laterally.Stress Axila View: Here knee is flexed to 35 at the end of x-rays table & a constant pressure isexerted at the patella in an attempt to displace it laterally. The symptomatic & asymptomatic kneesare compared.Sunrise View: The tangential view of patella is taken with the patient prone & knee flexed to 115.The central beam is directed towards the patella with 15 cephalic tilt.Merchant’s View: This view is taken with the knee flexed to 45 at the table’s edge with patient insupine position. The cassette is held perpendicular to the tibia at a distance of 10cms from knee level.The central beam is directed caudally through patella with 60 angle from vertical or 30 angle fromhorizontal.
    • Method of measurement:Step I. First sulcus angle is drawn as a zero reference line (It is the angle formed between the 2 femoral condyle & is around 141)Step II. A line is drawn bisecting the sulcus angleStep III. Second line is projected from the lowest point of articular ridge of patella to apex of sulcusStep IV. Angle formed between 2 lines is measured (congruence angle). If the congruence angle is lateral to congruence line the angle is positive, if it is medial to congruence line it is negative. Normal angle is less than -16 (males -6 & females -10 normally)Lateral X-rays: Patient lies flat on the affected side with the knee flexed 25-30. The central beamis directed toward the medial aspect of knee joint with 5-7 of cephalic tilt.It helps in detecting a. Patellar height b. Fabella lesions c. Evaluation of fat density zoneFat Density Zone: The suprapatellar pad of fat is seen as fat density zone behind the quadriceps. Injoint effusions it is displaced anteriorly.Fabella: Seen in 10 to 20% of individuals, it is seen embedded in lateral head of gastrocnemius.Patellar height: 2 methods of measurement:Insall & Salvati Method: In this method ratio of length of patella & length of patellar tendon ismeasured. A ratio less than 1 indicated patella alta. The length of tendon is measure on its posteriorsurface from the lower pole of patella to its insertion on top of tibial tubercle. Length of patella is thegreatest diagonal length of patella measured.Blackburne & Peel Method: It is the ratio between perpendicular distance from lower articularmargin of patella to tibial plateau (A) & the length of articular surface of patella (B)Tunnel Radiograph of Knee: It provides an angled PA projection of knee. Patient is prone withknee flexed at 40. The central beam is directed caudally toward the knee joint at a 40 angle fromthe vertical. It gives a good profile of intercondylar notch & posterosuperior articular surfaces offemoral condyle. It is specially useful in detecting osteochondritis dissecans.Rosenburg View For OA Knee: This view is used to evaluate for narrowing of the cartilage spacein posteroanterior flexion weight bearing radiograph. The film has anterior margin of tibial plateausuperimposed on the posterior marginMethod: Patient stands with knees flexed at 45, weight equally distributed on both extremities,patella touching the cassette & toes pointing straight forward. The x-ray machine is 40 inches fromthe cassette & central beam is directed at inferior pole of patella with 10 caudal tilt. Narrowing ofcartilage space of more than 2 mm is indicative of major degeneration (Grade III or IV)
    • Fracture Patella Osteomyelitis lower end Total knee replacementwith tension of femurband wiringUnicondylar knee replacement Complete PCL tear