Patella dislocation is a common problem in the young. Recurrence of dislocation can be significant problem causing pain and discomfort. The assessment and guidelines towards non-surgical and surgical treatment options are discussed here.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
ALL (antero-lateral ligament) - extra articular ACL reconstruction - basicsMilind Tanwar
history, need, how to reconstruct, when to reconstruct.
References: *Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015)
Biomechanical Results of Lateral Extra-articular
Tenodesis Procedures of the Knee:
A Systematic Review. Erik L. Slette, B.A., Jacob D. Mikula, B.S., Jason M. Schon, B.S., Daniel C. Marchetti, B.A.,
Matthew M. Kheir, B.S., Travis Lee Turnbull, Ph.D., and Robert F. LaPrade, M.D., Ph.D.
Patella dislocation is a common problem in the young. Recurrence of dislocation can be significant problem causing pain and discomfort. The assessment and guidelines towards non-surgical and surgical treatment options are discussed here.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
ALL (antero-lateral ligament) - extra articular ACL reconstruction - basicsMilind Tanwar
history, need, how to reconstruct, when to reconstruct.
References: *Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015)
Biomechanical Results of Lateral Extra-articular
Tenodesis Procedures of the Knee:
A Systematic Review. Erik L. Slette, B.A., Jacob D. Mikula, B.S., Jason M. Schon, B.S., Daniel C. Marchetti, B.A.,
Matthew M. Kheir, B.S., Travis Lee Turnbull, Ph.D., and Robert F. LaPrade, M.D., Ph.D.
Brief discussion regarding management of physiotherapy, pharmacotherapy, orthosis, principles of orthopedic surgical managements, addressing problems at hip, knee and ankle, soft tissue release procedures, osteotomies, timing of surgery, complications, prognosis, hip at risk signs, birthday syndrome, role of botulinum toxin, upper extremity involvement, contracture release.
complete Knee joint assessment from physiotherapeutic point of view. Includes observation , palpation , assessment, special test, differential diagnosis of knee joint .
1. Stage 2 – Posterior Tibial
Tendon Dysfunction
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd
3. Adult Acquired Flatfoot
Classification
Stage Tendon Deformity
I Degenerated None (mild)
II Elongated,
partial tear
Flexible, ↑heel valgus, possible
forefoot abduction
III Elongated,
Partial tear
Stiff/fixed: minimal heel
inversion
IV Elongated,
partial tear
Valgus ankle tilt
4. • A diverse constellation of deformity
• Numerous names:
• PTTI, PTTD, Adult Acquired Flatfoot (AAFD),
Adult Progressive Flatfoot, Collapsing Pes
Valgus
Combined tendon/ligament failure
5. Stage II
• Variability in amount and types of
flexible deformity
• Two groups
• IIa
• IIb
_________________________________
*J.T. Deland, et al. HSS Journal (2006) 2:157–160
*Vora, et al. JBJS Am.,2006; 88:1726 - 1734
*Bluman EM, et al. Foot Ankle Clin. 2007 Jun;12(2):233-49, v. Review.
6. IIa
• Less than 30% medial talar head uncoverage
(or no lateral incongruence)
• No clinical forefoot abduction
7. IIb
• More than 30% medial talar head uncoverage
or lateral incongruence
• Significant clinical forefoot abduction
9. Anatomy & Function
• PTT insertions
• Navicular tuberosity, navicularcuneiform capsule,
medial, middle & lateral cuneiforms, cuboid, bases of
2nd-5th MT’s, & sustantaculum tali (Sarrafian)
• PTT function
• Inversion of subtalar joint
• Adduction of forefoot
• Supination of forefoot
• Antagonist
• Peroneal brevis
10. Function/Biomechanics
• Initiates heel rise
• Invert subtalar joint
• Locking transverse tarsal jts
• GSC powerful inverter after
inversion initiated by posterior
tib
• Patients w/ PTT dysfunction
• Unable to initiate heel rise
• Able to maintain heel rise once
on their toes
11. Pathophysiology
• Unopposed pull of peroneal brevis
• forefoot abduction
• Attenuation in medial ligamentous structures
• Progressive collapse of arch
• End stage
• Marked calcaneal valgus
• Talus PF
• Forefoot abduction
12. Pathophysiology
• Spring Ligament
Complex
• Integrity of TN joint
• Superior medial
calcaneonavicular
ligament
• Inferior
calcaneonavicular
ligament
• Forefoot abd
attenuation of spring
ligament
• Talus PF & equinus
contracture
13. Etiology
• “Critical zone of hypovascularity”
• Medial malleolus to navicular
• Diabetes
• Hypertension
• Obesity
• Trauma
14. Clinical Presentation
• Stage II: Flexible deformity
• Postural changes
• Heel valgus
• Loss of arch
• Forefoot abduction/varus
• Tendinosis
• Weakness
• Normal subtalar motion
• Pain
• Initially medial lateral pain later
• Able to perform single toe rise early
• Unable to perform single toe rise late
15. Physical Exam
• Observation (front & behind)
• Deformity
• Fullness behind medial malleolus
• Single toe raise
• Evaluate TMT joints for
arthrosis/hypermobility (can mimic
PTT dysfunction)
16. Physical Exam
• Range of motion
• Muscle strength testing
• Swelling @ PTT
• Tenderness @
PTT/sinus tarsi
17. X-rays
• WB AP Foot
• Talo-2nd MT angle
• Lateral subluxation of
TN joint
18. X-rays
• WB Lateral Foot
• Sag of TN joint
• Talo-1st MT angle (Meary’s angle)
• Height of medial cuneiform or MT overlap
19. X-rays
• WB Ankle Series
• Hindfoot alignment view
• MRI
• Controversial in its role
20. Conservative Treatment
• Orthotic w/ medial heel lift, longitudinal
arch, medial forefoot post
• MAFO/Arizona brace
• For more severe flexible deformities
• UCBL to block abduction of forefoot
• Difficult to make
Chao & Wapner, CORR, 1999
21. Surgical Treatment
• Stage II: controversial
• Early
• FDL transfer
• Medial displacement calcaneal osteotomy
• Late
• Add
• Lateral column
• Lengthening/Evans
• CC fusion
• TAL
• Medial column procedure
• Cotton, Lapidus, PF osteotomy
• Spring ligament
• Repair vs reconstruction vs TN fusion
23. FDL Transfer
• Medial midline incision
• Retract addHal
• Knot of Henry
• Formal tenodesis
• Transfer through drill hole in navicular
• Tie at end of case
• Foot maximal inversion
25. FDL Only
• Stage II (flexible deformity)
• FDL transfer
• Results (Mann & Thompson)
• 88% satisfied
• 7/11 not satisfied had fixed hindfoot or forefoot
deformity
• No significant improvement in arch height
radiographically
26. Medial Displacement
Calcaneal Slide
• Theory
• Change the mechanical axis of the Achilles
• Improves inversion power
• Shifts weight bearing axis towards long axis of
tibia
• Usage
• Hindfoot valgus deformity
37. LCL/ Evans Osteotomy
•Supine
•Incision
•Lateral over ant process
•SURAL, PERONEALS
•Find CC joint
•Retract peroneals
inferiorly
•Measure 1.5cm proximal
to CC joint
•Score periosteum
•TPS saw
•Bounce blade
46. Lateral Column Procedures
• Lateral column lengthening
• Restores arch height & talar head
coverage
• Evans procedure
• Opening wedge calcaneal
osteotomy
• CC joint fusion
• Loss 30-50% subtalar motion
• Complete loss transverse tarsal
motion
Courtesy of Chi, et. al., CORR, 1999
47. Lateral Column Pain
• Thomas RL, et al. Preliminary results comparing
two Methods of lateral column lengthening. Foot
Ankle Int. 2001; 22(2):107-19.
• 3/34 (9%) feet w persistent lateral pain
• J.T. Deland, et al. Posterior Tibial Tendon
Insufficiency Results at Different Stages. HSSJ
(2006) 2:157–160
• 8% w pain
• 45% (10 feet of 22) w discomfort
48. Other Ligaments
• Other ligaments/joints likely fail: may be
combination
• Flatfoot variants:
• Collapse through TMT joints
• Collapse through TN joints
