This document discusses patellofemoral instability, including its anatomy, biomechanics, evaluation, and management. It begins by introducing patellofemoral instability as a common orthopedic problem. Key anatomical structures that provide stability to the patellofemoral joint are described, including the trochlear groove, medial patellofemoral ligament, and quadriceps muscle. Evaluation involves assessing factors like the Q-angle, patellar tracking and tilt, and imaging findings. Management depends on whether the instability is acute or recurrent/chronic. For recurrent patellar dislocations, various surgical procedures are discussed to address underlying anatomical abnormalities, including medial patellofemoral ligament reconstruction, tibial tubercle osteotomy
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.
Medial patellofemoral ligament.
stabilizer of patella during initial 30 degree of flexion.
More than 18 techniques of reconstruction described.
Runs in layer 2 on medial aspect of the knee.
Origin- 1.9mm anterior/3.8 mm distal to adductor tubercle.(Laparade JBJS- Am.07)
Insertion – proximal 2/3 of patella
Along Distal edge of VMO
Broad insertion over 28.2+_ 5.6 mm over proximal 2/3 patella.
Average length 59.8mm +_ 4.8mm.
Passive- Trochlear constraints
Depth ,length(Height)
Patellar engagement
Capsular ligamentous tethers, especially MPFL
(Hautamaa, Fithian et al. 1998)
Dynamic elements
Simulated muscle tension has little effect on patellar mobility. Regardless of flexion angle
(Scnavongers, Farahmand et al 2003
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.
Medial patellofemoral ligament.
stabilizer of patella during initial 30 degree of flexion.
More than 18 techniques of reconstruction described.
Runs in layer 2 on medial aspect of the knee.
Origin- 1.9mm anterior/3.8 mm distal to adductor tubercle.(Laparade JBJS- Am.07)
Insertion – proximal 2/3 of patella
Along Distal edge of VMO
Broad insertion over 28.2+_ 5.6 mm over proximal 2/3 patella.
Average length 59.8mm +_ 4.8mm.
Passive- Trochlear constraints
Depth ,length(Height)
Patellar engagement
Capsular ligamentous tethers, especially MPFL
(Hautamaa, Fithian et al. 1998)
Dynamic elements
Simulated muscle tension has little effect on patellar mobility. Regardless of flexion angle
(Scnavongers, Farahmand et al 2003
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
This presentation goes in depth about Primary and Recurrent Patellar dislocation. Its cause, clinical and radiographic evaluation and various modalities of management with update from latest literature.
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
This presentation goes in depth about Primary and Recurrent Patellar dislocation. Its cause, clinical and radiographic evaluation and various modalities of management with update from latest literature.
A Baker’s cyst is usually the result of a problem with your knee joint, such as arthritis or a cartilage tear. Both conditions can cause your knee to produce too much fluid, which can lead to a Baker’s cyst.
Bakers cyst symptoms, causes, diagnosis, & treatmentSpinalogy Clinic
A Baker's cyst, also known as a popliteal cyst, is a benign swelling of the semimembranosus or more rarely some other synovial bursa found behind the knee joint.
Prof. Anisuddin Bhatti, Paediatric Orthopaedic Surgeon, Dr. Ziauddin University Hospital, Clifton campus Karachi, presented lecture on Congenital Clubfoot and PPV deformity evaluation & treatment. On 31 May 2021 to Resident's of AKUH and others. Acknowledged text & picture source as indicated in reference list.
Patellofemoral Pain
Patellofemoral pain (PFP) is a common musculoskeletal related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retro patellar and/or peripatellar region of the knee.
An overuse injury in sports medicine.
Commonly known as “runner’s knee.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
1. PTELLOFEMORAL INSTABILITY
Dr.G.Ramesh
M.S(Ortho)
Asst.Professor
Dept. of Orthopaedics
Gandhi Medical College
Secunderabad
2. PATELLO FEMORAL INSTABILITY
INTRODUCTION:
patello femoral instability is a common but challenging treatment problem for an
orthopaedic surgeon
The patellofemoral joint has a low degree of congruency by nature, hence it is
susceptible to dislocation
Dislocation is a result of anatomical abnormalities and/or insufficient soft tissue
restraints
Non-surgical approaches have been advocated to treat acute patellar
dislocation, while many operative procedures, including proximal soft tissue or
distal bony realignment procedures are designed to treat chronic / recurrent
patellar dislocations
Addressing the specifics of anatomy, biomechanics, history, physical examination
, and radiographic interpretation can shed important light on the treatment
options of acute and recurrent patellar dislocations/and subluxations
4. PATELLO FEMORAL INSTABILITY
Biomechanics
stability and normal tracking of the patella with knee flexion requires a
complex co ordination of static and dynamic stabilizers. From o° to 30° of
the knee flexion, medial patello femoral ligament and other soft tissue are
primary restraints to lateral patellofemoral dislocation. With the greater
knee flexion , the bony confines of the lateral femoral condoyle and
trochlear groove captures the patella and patellar stability
5. PATHOLOGIC ANATOMY OF PATELLAR DISLOCATION
H. dejour classification
Primary instability factors
1. Trochlear dysplasia
2. Patella alta
3. Patella tilt
4. ↑ TT-TG distance(‘q’ angle quantification by CT scan)
Secondary instability factors
1. Excessive external femoral rotation / Excessive femoral ante version
2. Excessive external tibial rotation
3. Genu valgum
4. Genu recurvatum
( these underlying pathologies predispose to an acute over load of soft tissue
stabilizers and rupture of MPFL with patellar dislocation following minimal trauma)
6. PATELLO FEMORAL INSTABILITY
Who tends to recur
• Young
• Female
• Family history
• Bilateral
• Atraumatic disorders
• Anatomic abnormalities
patella alta
trohlear hypoplasia
↑TT-TG distance
↑ ‘q’ angle
quadriceps dysfunction
hyper mobility
7. PATELLO FEMORAL INSTABILITY
Evaluation
We evaluate the following features
1. Integrity of medial patello femoral ligament
2. Height of patella on physical and radiographic examination
3. Length of patellar tendon
4. Position of patella in relationship to trochlea
9. PATELLO FEMORAL INSTABILITY
physical examination
gait
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignment
for males : mean ‘Q’ angle is 10͔°
for females : mean ’Q’ angle is 15°±5°
↑’q’ angle leads to relative lateral shift of patella
↑’Q’ angle results from
↑femoral external rotation
↑external rotation
genu valgum
tibia vara
10. PATELLO FEMORAL INSTABILITY
physical examination
gait
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignment
observe the movement of the patella during active knee extension,
lateral subluxation of the patella as the knee approaches full extension
is indicative of j sign positive
positive j sign indicates ↑ lateral force or ↑ ‘q’angle
11. PATELLO FEMORAL INSTABILITY
physical examination
gait
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignment
patellar laxity
patellar translation is assessed by passively
moving patella medially and laterally with
knee at 0° and 30° of flexion, the amount of
translation is quantified in quadrants. Normal
glide is one but more than two quadrants indicates
laxity
12. PATELLO FEMORAL INSTABILITY
physical examination
gait
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignment
patellar tilt
it is done with knee in full extension
normally patella can be tilted so that
the lateral edge is well anterior to the
medial edge
inability to do this indicates lateral
retinacular tightness
13. PATELLO FEMORAL INSTABILITY
physical examination
gait external tibial torsion
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignment
Measured by he relation ship of the transmalleolar axis to the Coronal axis of the
proximal tibia, is typically neutral
tibial torsion also may be assessed through measurement of the thigh-foot
angle, average values are 5°internal
leads to ↑’Q’ angle and ↑ TT-TG distance
14. PATELLO FEMORAL INSTABILITY
physical examination
gait excessive femoral ante version
standing alignment
‘Q’ angle
J sign
laxity
rotational malalignmen
measured by hip rotations with the patient in prone position with hips extended and
knees at 90°of flexion
Normal range of hip rotations are about 45°. With ↑ femoral antevertion range of I.R.
increases and range of E.R. reduced
conditions leads to ↑’q’angle and
↑TT-TG distance
15. PATELLO FEMORAL INSTABILITY
Radiographic evaluation
1. long standing weight bearing hip-to-ankle, A.P view
helps in assessing the angular deformity of knee
i.e. genu varum and genu valgum
16. ..
PATELLO FEMORAL INSTABILITY
Radiographic evaluation
Lateral view with 30° of knee flexion
Insall-salvati ratio:
normal value: 1.0 to 1.2
↑value indicates: patella alta
When patella alta is present ,the patella becomes engaged with greater degrees of
knee flexion , where the patella is not captured and it is at increased risk for
instability
18. PATELLO FEMORAL INSTABILITY
Radiographic evaluation
Merchants view: tangential axial view of patello femoral joint obtained with knee in 45° of flexion
Sulcus angle
normal angle : 140°
> 140° : trochlear dysplasia
Congruence Angle
normal : -8°to+14°
>14° indicates lateral subluxation
Lateral Patello Femoral Angle
normal: angle opens laterally
abnormal : angle opens medially
or lines become parallel
19. PATELLO FEMORAL INSTABILITY
CT scan evaluation
• Helps in assessing the bony anatomy and architecture of patello femoral joint at different
angles of knee flexion
• The protocol includes mid-axial images obtained from 0°to60° of flexion in 10° of increments
• Is quantification of ‘q’ angle
TT-TG distance : normal measures are 2to 9 mm
borderline measures are 10to 19 mm
pathological > 20°
Sulcus angle
Congruence angle
Trochlear depth
20. PATELLO FEMORAL INSTABILITY
CT scan evaluation
The protocol includes mid-axial images obtained from 0°to60° of flexion in 10° of increments
21. MANAGEMENT OF PATELLO FEMORAL INSTABILITY
Types of patellar dislocations
Acute patellar dislocations
Chronic / recurrent patellar dislocations
Acute patellar dislocations
Results from high energy transfer, where anatomy of joint is normal
Results from internal rotation of femur on a fixed externally rotated tibia
Major sequelae of acute patellar dislocation is tear of medial patello
femoral ligament (MPFL)
In general most acute dislocations are treated non-operatively unless
associated with an osteochondral injury
When surgery is needed MPFL is repaired / reconstructed
22. MANAGEMENT OF RECURRENT PATELLAR INSTABILITY
Defined as the condition where patellar dislocation had occurred at least
twice, or where patellar instability following initial dislocation had
persisted for more than three months
A large number of procedures have been described to treat recurrent
patellar dislocations
No single surgery is universally successful in correcting the chronic patellar
instability
We need to customize surgery based on the knee problem
Our approach is to identify the underlying problem that cause the patello
femoral instability and systemically correct them
23. MANAGEMENT OF RECURRENT PATELLAR INSTABILITY
The surgical procedures are classified into
Proximal Realignment Of Extensor Mechanism
1.Lateral retinacular release
2. Medial plication/ reefing
3. VMO advancement
4.MPFL reconstruction
Distal Realignment Of Extensor Mechanism
Medial or antero medial displacement of tibial tuberosity
24. MEDIAL PATELLO FEMORAL LIGAMENT RECONSTRUCTION
The procedures like medial plication, vmo advancement, and lateral
retinacular release are non anatomic procedures
They don’t address the principle of pathology in recurrent patellar
dislocation
Medial patello femoral ligament (MPFL) is the primary soft tissue passive
restraint to pathologic lateral patellar dislocation, and MPFL is torn when
patella dislocates, hence reconstruction of MPFL is done in an attempt to
restore its function as a checkrein
25. MEDIAL PATELLO FEMORAL LIGAMENT RECONSTRUCTION
Anatomy of medial patellofemoral ligament
MPFL arises from medial surface upper two thirds of patella above
equator and inserts into a groove between adductor tubercle and medial
epicondyle
26. MEDIAL PATELLO FEMORAL LIGAMENT RECONSTRUCTION
Procedure
indicated in : skeletally mature patient
excessive lateral laxity normal trochlea
‘Q’ angle is normal
TT-TG distance is < 20mm
low grade trochlear dysplasia
Contraindications : skeletally immature patients
where MPFL is normal
27. MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION
Procedure
Examination under anaesthesia
Hamstring graft preparation
Exposer of MPFL
29. DISTAL REALIGNMENT SURGERY
Fullkerson antero-medial tibial tuberosity transfer
aims to diminish the q angle or TT-TG distance with medialisation of tibial tuberosity and
unloads patello femoral articulation with anteriorisation of the tubercle
Indications
1. ↑ Q angle or ↑ TT-TG distance > 20mm
2. Patellar alta
3. Normal patellar glide
4. Medial facet arthritis
Contraindications
1. Skeletally immature patients
2. incompetent MPFL
3. Diffuse patellar arthritis
30. Fullkerson antero-medial tibial tuberosity transfer
Procedure
Routine lateral retinacular release is done
An oblique osteotomy is made from ateromedially close to anterior tibial crest
directed in postero lateral direction ,existing at lateral cortex posteriorly
Mitek tracker drill guide with cutting slot is used to define precise osteotomy plane
Bone pedicle is displaced in an antero medial direction usually about 12to 17mm
of anterization depending on obliquity of osteotomy
31. TROCHLEAR DYSPLASIA
The normal trochlea is located in the anterior aspect of the distal femur. It is
composed of two facets divided by the trochlear sulcus
The lateral facet is the biggest, it extends more proximally than medial facet and is
more protuberant in A.P. Aspect
Dysplastic trochleas are shallow, flat or convex
These trochleas are not effective in constraining mediolateral patellar
displacement
Is defined by a sulcus angle > 140°
32. TROCHLEAR DYSPLASIA
Radiological features
X- ray lateral projection of normal trochlea will typically show the contour of
the facets, and posterior to them, the line representing the bottom of the
sulcus is visualized and is continues with the intercondylarnotch line
33. TROCHLEAR DYSPLASIA
Radiological features
Crossing sign
The radiographic line of trochlear sulcus crosses he projection of the femoral
condyles
The crossing point represents the exact location of the deepest point of trochlear
sulcus which is about 0.8mm posterior to a line projected from anterior femoral
cortex, in dysplastic trochlea it’s an point is 3.2mm forward to same
36. TROCHLEAR DYSPLASIA
Classification of trochlear dysplasia
Type A: crossing sign +
the trochlea is shallower than normal, but still symmetrical and
concave
Type B: crossing sign +
supratrochlear spur +
the trochlea is flat or convex in axial view
37. TROCHLEAR DYSPLASIA
Classification of trochlear dysplasia
Type C: crossing sign +
double-contour sign +
supratrochlear spur –
representing hypoplasia of medial facet and lateral facet convex
Type D: crossing sign +
double-contour sign+
supratrochlear spur +
clear asymmetry of the height of facets, and referred to as a cliff pattern
38. MANAGEMENT OF TROCHLEAR DYSPLASIA
Surgical indications
High grade trochlear dysplasia with patellar instability in the absence of
patellofemoral osteoarthritis
Type of dysplasia should be identified when deciding the procedure
Associated abnormalities including TT-TG distance, patellar alta, patellar
tilt should be identified and rectified
MPFL reconstruction is always done
Contra indications
Skeletally immature patients
Associated osteoarthritis
39. MANAGEMENT OF TROCHLEAR DYSPLASIA
Type of dysplasia and surgical procedure
Type A dysplasia : medial patellofemoral ligament reconstruction
Type B and D dysplasia : sulcus deepening trochleoplasty with MPFL
reconstruction
Type C dysplasia : lateral facet elevation trochleoplasty with MPFL
reconstruction
40. MANAGEMENT OF TROCHLEAR DYSPLASIA
Procedure: sulcus deepening trochleoplasty by Henrey Dejour
Indicated in type B and D trochlear dysplasia with patellar dislocation
It is designed to establish a new trochlear groove of correct length and tilt
, addressing the root cause of patellar dislocation due to trochlear dysplasia
The femoral trochlea is deepened by removing the subchondral trochlear
bone followed by incision, impaction, and fixation of cartilage flare along the
trochlear groove
43. CONCLUSION
Patellofemoral instability can be difficult to treat
Acute patello femoral dislocations should be treated with immobilization
and rehabilitation. Arthroscopy should be indicated for symptomatic
osteochondral injury
In recurrent patellofemoral dislocations, it is important to understand
each patients reason for repeated instability.
The reason can be determined through a detailed history, focused physical
examination, and radiographic studies including CT scan and MRI
Once determined proximal realignment procedures, distal realignment
procedures, trochleoplasty or a combination of above procedures can be
tailored to the individual patient and be utilized to correct patellofemoral
biomechanics