DisordersDisorders ofof thethe KneeKnee PainPain Swelling,Swelling, effusioneffusion oror hemarthrosishemarthrosis LimitedLimited jointjoint motionmotion Screw home mechanism – pain, stiffness, fluid, muscular weakness, locking InstabilityInstability – giving way, laxity DeformityDeformity

References: 1. Canale ST. Campbell’s operative orthopaedics. 10th edition 2003 Mosby, Inc. 2. Netter FH. The Netter collection of Medical illustrations – musculoskeletal system, Part I & II. 1997 Novartis Pharmaceuticals Corporation. 3. Magee DJ. Orthopedic Physical assessment. 2nd edition 1992 W. B. Saunders Company. 4. Hoppenfeld S. Physical examination of the spine and extremities. 1976 Appleton-century-crofts. AnteriorAnterior CruciateCruciate LigamentLigament

Tibial insertion – broad, irregular, diamond-shaped area located directly in front of the intercondylar eminence Femoral attachment Femoral attachment Figure 43-24 In addition to their – semicircular area on the posteromedial synergistic functions, cruciate aspect of the lateral condyle and collateral ligaments exercise 33 mm in length basic antagonistic function 11 mm in diameter during rotation. A, In external Anteromedial bundle — tight in flexion rotation it is collateral ligaments that tighten and inhibit excessive Posterolateral bundle — tight in extension rotation by becoming crossed in 90% type I collagen space. B, In neutral rotation none 10% type III collagen of the four ligaments is under unusual tension. C, In internal Middle geniculate artery rotation collateral ligaments Fat pad (inferior medial & lateral become more vertical and are geniculate arteries) more lax, while cruciate Primary restraint (85%) to anterior ligaments become coiled around translation each other and come under strong tension. PosteriorPosterior CruciateCruciate LigamentLigament Tibial insertion – a sulcus posteriorly, below the articular surface of the tibia Femoral attachment – broad half-moon or crescent shape anterolaterally on the medial femoral condyle 38 mm in length 13 mm in diameter Figure 28-A-2 The four-bar Anterolateral bundle — tight in flexion cruciate linkage model. The model includes two crossed Posteromedial bundle — tight in extension bars, which represent the Anterior meniscofemoral ligament anterior and posterior cruciate (Humphry) ligaments (ACL; PCL). The remaining two bars represent posterior meniscofemoral ligament the tibial and femoral (Wrisberg) attachments of the ligaments. Middle geniculate artery IC, instantaneous center of rotation. Primary restraint (95%) against posterior tibial displacement MedialMedial CollateralCollateral LigamentLigament Superficial (tibial collateral ligament) – anterior — tighten during the first 90° of motion – posterior — tighten in extension Deep (middle capsular ligament) – meniscofemoral ligament – meniscotibial (conorary) ligament PrimaryPrimary restraintrestraint toto Figure 43-11 Fibers of tibial collateral ligament. Points A and B are at anterior border of long fibers. C is 5 mm LCLLCL (Fibular(Fibular CollateralCollateralvalgusvalgus Ligament)Ligament) posterior to B. Tightest in extension, relax angulationangulationin flexion Primary restraint to varus angulation PosteolateralPosteolateral ComplexComplex (PLC)(PLC) Popliteus tendon Arcuate complex LCL FunctionsFunctions ofof MenisciMenisci

AidAid inin loadload transmissiontransmission ReduceReduce stressstress onon articulararticular surfacesurface ContributeContribute toto jointjoint stabilitystability AidAid inin lubricationlubrication SupplySupply chondralchondral nutritionnutrition MedialMedial MeniscusMeniscus Peripheral 20 – 30% vascularized (medial genicular artery) More “C” shaped

LateralLateral MeniscusMeniscus Peripheral 10 – 25% vascularized (lateral genicular artery), also less vascular in the area of popliteal hiatus Incomplete “O” shaped

TransverseTransverse ((IntermeniscalIntermeniscal)) LigamentLigament MeniscalMeniscal HealingHealing andand RepairRepair

Figure 43-34 Superior aspect of medial (A) and lateral (B) Figure 43-35 Frontal section of menisci after vascular perfusion with India ink and medial compartment of . tissue clearing using modified Spaltheholz technique. Branching radial vessels from Note vascularity at periphery of , as well as at perimeniscal capillary plexus anterior and posterior horn attachments. Absence of (PCP) can be seen penetrating peripheral vasculature at posterolateral corner of lateral peripheral border of medial meniscus (arrow) represents area of passage of meniscus. F, Femur; T, tibia. popliteal tendon. HistoryHistory TakingTaking

Figure 43-25 Movement of femur relative to tibia during flexion, showing contact points generated by combination of rolling and PhysicalPhysical ExaminationExamination gliding. This represents true physiological action of tibiofemoral joint. Inspection (active & passive) Neurologic examination Tests (signs) Figure 28-A-1 Coordinate system for knee joint rotations Referred pain and translations. Flexion-extension rotation is about the fixed femoral axis. Internal-external rotation is about a fixed tibial axis. Abduction-adduction is about an axis that is perpendicular to the femoral and tibial axes. The joint translations occur along each of the three coordinate axes. The mechanical axis of the leg is measured in the standing position with InspectionInspection an imaginary “plumb line” dropped from the femoral head to the ground. Malalignment – genu valgum (knock-knee), genu varum (bowleg), genu recuvatum (back knee) Swelling, effusion, skin integrity, ecchymosis, erythema Patella position The anatomic axis is measured by drawing lines parallel to the long axis of the femur and the tibia and measuring the intercepting angle. – patella alta, patella baja, small patella, camel sign, squinting patella, grasshopper or frog eyes appearance Leg length discrepancy, deformity (eg, pigeon- toed foot deformity), gait

PalpationPalpation

TendernessTenderness (location(location && degree)degree) SwellingSwelling EffusionEffusion DeformityDeformity (contour,(contour, mobilitymobility ofof patella)patella) ThighThigh circumferencecircumference TestsTests (Signs)(Signs)

EffusionEffusion – (), fluctuation, balloon, brush or stroke MeniscusMeniscus – McMurray, Apley compression & distraction, O’Donoghue, bounce home, Steinman, modified Helfet, Payr, Bohler sign, Bragard sign, Kromer sign, Childress sign, Anderson med-lateral grind, Passler rotational grinding, Cabot popliteal sign

TestsTests (Signs)(Signs) CollateralCollateral ligamentsligaments – valgus (abduction) stress, varus (adduction) stress AnteriorAnterior instabilityinstability

– Lachman, anterior drawer Figure 43-44 Abduction stress test. ((FinodriettoFinodrietto PosteriorPosterior instabilityinstability jumpingjumping sign)sign) – posterior “sag” sign (gravity drawer), quadriceps contraction,sign)sign) reverse Lachman, posterior drawer, Godfrey, deceleration, disco ((MerkeMerke , leaning hop, one-leg hop Figure 43-47 Anterior . A, In resting Figure 43-49 for anterior position tibial plateau is held in normal position by cruciate instability. intact posterior cruciate ligament. B and C, With anterior cruciate insufficiency tibia can be pulled forward against force of gravity and tone of flexors. Figure 43-51 With posterior drawer testing, loss of normal step-off of medial tibial plateau with respect to medial femoral condyle indicates posterior cruciate ligament tear.

Figure 43-53 “Posterior drawer” often is mistaken for “anterior Figure 43-54 Quadriceps drawer” because tibia sags posteriorly and appears to move active test for posterior abnormal distance forward when examiner tests for anterior cruciate ligament deficiency. drawer phenomenon. A, “Posterior sag” of right tibia is obvious when compared with normal silhouette of healthy knee joint. B, Tibial sag in resting position. If patient starts to raise his foot from this position, pull of quadriceps first displaces tibia anteriorly into neutral position until anterior cruciate ligament is tight (C). Only then is foot raised from table (D). E, Same knee joint as in A now manually restored to its normal position. Both silhouettes are now equal. F, “Drop back” or sagging of tibia in foreground in relation to femur in presence of posterior cruciate disruption. TestsTests (Signs)(Signs) Anteromedial rotary instability – Slocum Anterolateral rotary instability – Slocum, lateral pivot-shift (MacIntosh or Lemaire), active pivot-shift, Losee, jerk (Hughston), crossover (Arnold), Noyes (flexion-rotation drawer), flexion- extension-valgus, Nakajima (“N”), Martens Posteromedial rotary instability – Hughston posteromedial and posterolateral drawer sign Posterolateral rotary instability – Hughston posteromedial and Figure 43-62 Demonstration – Hughston posteromedial and of shift in vertical axis away posterolateral drawer sign, Jakob from center of tibia as tibia (reverse pivot-shift), external rotation shifts excessively and recurvatum, dynamic posterior shift, abnormally in relation to active posterolateral drawer sign, femur. Position of femur is Loomer posterolateral rotatory instabilitydesignated by shaded area. TestsTests (Signs)(Signs)

PlicaPlica – mediopatellar plica, plica “stutter”, Hughston plica PatellaPatella – (Noble) compression & grinding (inhibition), (Fairbank) apprehension, J sign, passive patellar tilt, Clarke sign, Waldron, McConnell, lateral pull, Zohler sign, Frund sign, Dreyer, Q angle (P-F angle), Daniel quadriceps neutral angle, Wilson TinelTinel sign,sign, NobleNoble compressioncompression (ITB)(ITB) Quadriceps (Q) angle Figure 45-5 Roentgenographic techniques for evaluation of patellofemoral joint. A, Infrapatellar view. B, Axial view. C, Skyline view.

Figure 45-7 Measurements of patellofemoral congruence. M, medial condyle; L, lateral condyle; S, sulcus; P, patellar ridge; F, facet. Angle MSL is the sulcus angle (average, 137x; SD, 6x). Line SO is the zero reference line bisecting the sulcus angle. Angle PSO is the congruence angle (average, −8x; SD, 6x). Line PF (lateral facet) and line ML form the patellofemoral angle that should diverge laterally.

Figure 45-6 Lateral tilt of patella on axial view. OtherOther DiagnosticDiagnostic StudiesStudies Roentgenography Nuclear imaging – stress fracture, early arthritis, reflex sympathetic dystrophy (RSD), osteonecrosis Magnetic resonance imaging (MRI) – ligament injury, meniscal pathology, articular injury Computed tomography – bony lesion, patellar tilt, certain fracture CT arthrography – articular surfaces of the P-F joint, patient cannot tolerate MRI Thermography – RSD (limited case) Figure 43-37 of knee showing tear Ultrasonography of meniscus. – patellar tendinitis, hematoma, soft tissue lesion Figure 48-1 A, Suprapatellar pouch with view of undersurface of articularis genu. B, Tangential view of patellofemoral articulation. C, Normal medial parapatellar plica. D, Posteromedial compartment is seen by passing arthroscope through intercondylar notch after viewing medial compartment. E, Posteromedial compartment as seen through posteromedial portal, which is made after completion of routine examination if complete posteromedial view is not satisfactory. F, Medial meniscus and medial compartment. G, Cruciate ligaments with fatty synovium covering posterior cruciate ligament. H, View of lateral meniscus and lateral compartment. I, View of posterior horn of lateral meniscus and popliteal tendon though hiatus. J, Posterolateral view of knee with arthroscope in anterolateral portal showing popliteal tendon insertioninsertion into femur in popliteal hiatus. InternalInternal DerangementDerangement InternalInternal derangementderangement (1784) by William Hey, a variety of intraarticular and extraarticular disturbances, usually of traumatic origin, interfere with the function of the joint “Deranged” – a keen sense of clinical judgment – roentgenograms – MRI – arthroscopy – at times, surgical exploration

Figure 43-26 Proposed scheme to explain relationship between mechanical alterations in knee joint and biological response. InternalInternal DerangementDerangement ofof thethe KneeKnee

Etiology – sports, trauma (injury), congenital Figure 48-8 A, Calcified stump of Symptoms anterior cruciate ligament after chronic tear. B, Empty lateral wall – pain, swelling, tender, effusion, sign indicating anterior-cruciate- pain & decrease of ROM ligament-deficient knee; anterior cruciate ligament can be attached to Physical examination posterior cruciate ligament, giving Radiographs false indication of functional ligament. – AP, lateral, Merchant MRI (if indicated)

Arthroscopy Figure 48-4 A, Bucket handle tear of – menisci (medial & lateral), medial meniscus that has flipped into intercondylar notch; in this position, ligaments (ACL, PCL, MCL, PLC), meniscus may cause intermittent cartilage, , synovium & plica symptoms. B, Locked bucket handle tear of medial meniscus. LigamentLigament InjuriesInjuries && InstabilityInstability ValgusValgus (MCL)(MCL) VarusVarus (LCL)(LCL) AnteriorAnterior (ACL)(ACL)

PosteriorPosterior (PCL)(PCL) Figure 43-45 Ligamentous lesions and associated passive instability. A, Tear confined to tibial collateral ligament; posterior corner and posterior capsule (shaded) are intact. Valgus stress applied to knee will not cause medial opening. This is possible only when knee is flexed about 30 degrees to relax posterior capsule, thereby eliminating its lateral stabilizing action. B, If knee Figure 48-2 A, Grade I medial capsular sprain in shows medial opening in extension, patient with torn anterior cruciate ligament. B, involvement of cruciate ligament is Grade II sprain of medial collateral ligament, with possibility even if no significant drawer some mild laxity of meniscotibial ligament as sign can be elicited. C, If valgus evidenced by abnormal elevation of meniscus off instability extends across to lateral side tibial articular surface when valgus stress is in both flexion and extension, both applied. cruciate ligaments are torn. Figure 14-14 Meyers and McKeever's classification of fractures of the anterior tibial spine. A, Type I fracture with no displacement of the fracture. B, Type II fracture with elevation of the anterior portion of the anterior Figure 43-128 Treatment algorithm for tibial spine, but with the fracture posteriorly posterior cruciate ligament avulsion reduced. C, Type III fracture that is totally fracture. displaced.

Figure 43-102 Repair of avulsion of tibial attachment of anterior cruciate ligament with fragment of bone. Crater in Figure 43-129 Screw tibia should be deepened, reattachment of bone and bone fragment on end fragment avulsed with of ligament is pulled into posterior cruciate crater depth to restore ligament from posterior tension in avulsed ligament. tibia. Figure 43-132 Treatment algorithm for chronic posterior cruciate ligament injuries. ClassificationsClassifications ofof TearsTears ofof thethe MenisciMenisci < based on location oror typetype ofof tear, etiology, and other factors > << mostmost ofof thethe commonlycommonly usedused classificationsclassifications areare basedbased onon thethe typetype ofof teartear foundfound atat surgerysurgery >> Longitudinal tears Transverse and oblique tears A combination of longitudinal and transverse tears Tears associated with cystic menisci Tears associated with discoiddiscoid meniscimenisci OO’’ConnorConnor ClassificationClassification ofof MeniscalMeniscal TearsTears

LongitudinalLongitudinal tearstears HorizontalHorizontal tearstears Figure 48-9 Four basic Figure 48-10 ObliqueOblique tearstears patterns of meniscal tears: I, Bucket handle longitudinal; II, horizontal; III, tear, displaced RadialRadial tearstears oblique; and IV, radial. centrally. Variations,Variations, includeinclude –– flapflap tearstears –– complexcomplex tearstears –– degenerativedegenerative tearstears Figure 48-11 Figure 48-12 A, Peripheral tears. A, Posterior oblique Meniscocapsular tear. B, anterior tear. B, Peripheral oblique tear. longitudinal tear. TypesTypes OfOf MeniscalMeniscal ExcisionsExcisions (O(O’’Connor)Connor)

Partial meniscectomy Subtotal meniscectomy Total meniscectomy

Figure 48-14 Types of meniscal excision. A, Partial meniscectomy. B, Subtotal meniscectomy. C, Total meniscectomy.

Figure 48-3 A, Complete tear of anterior cruciate ligament. B, Horizontal tear of degenerative lateral meniscus. C, Oblique tear of posterior horn of lateral meniscus. D, Incomplete radial tear of lateral meniscus. E, Degenerative tear of lateral meniscus. F, Resection of tear of lateral meniscus. Remaining tissue shows fatty degeneration. Figure 43-38 Zones of potential meniscal healing.

Figure 43-39 A, Through posteromedial multiple interrupted sutures placed vertically through periphery of meniscus are spaced every few millimeters and tied outside joint capsule. B, Looking down on top of longitudinal tear of meniscus with multiple reapproximating sutures. C, Sutures tied outside capsule reapproximating capsule or peripheral meniscal rim to body of meniscus.

Figure 43-40 Meniscal allograft. Figure 43-41 Cyst of lateral meniscus. PatellofemoralPatellofemoral DisordersDisorders Lateral patellar compression syndrome Patellar subluxation & dislocation – acute dislocation of the patella – chronic subluxation of the patella – recurrent dislocation of the patella – chronic dislocation of the patella Figure 14-8 Diagrammatic Chondromalacia of patella representation of an osteochondral fracture of the Patellofemoral arthritis lateral femoral condyle (B) and the medial pole of the patella (A), both secondary to patellar dislocation. Radiographs may appear normal, but the hemarthrosis aspirate will contain fat droplets. Arthroscopy is indicated when these chondral or osteochondral fractures are suspected.

Figure 48-9 Patellofemoral articulation viewed from anterolateral portal. A, Lateral tracking of patella is evident, as is grade II chondromalacia of lateral facet. B, Grade IV chondromalacia of trochlea with bare bone exposed. EtiologicalEtiological FactorsFactors inin ChondromalaciaChondromalacia ofof PatellaPatella Biomechanical causes – acute dislocation of the patella with a chondral or osteochondral fracture direct trauma (e.g., a fall on or a blow to the patella) fracture of the patella, resulting in incongruous surfaces – chronic recurrent subluxation or dislocation of the patella (secondary to femoral dysplasia, small patella, patella alta, femoral anteversion, external tibial torsion, or even anterior cruciate ligament insufficiency) increased quadriceps angle quadriceps muscle imbalance, either weakness or abnormal attachment of the vastus medialis patella alta posttraumatic malalignment following femoral shaft fracture excessive lateral pressure syndrome meniscal injury with alteration of synchronous pattern of patellar movement and loss of stability reflex sympathetic dystrophy medial femoral condylar ridge Biochemical causes – disease rheumatoid arthritis recurrent hemarthrosis alkaptonuria peripheral synovitis sepsis and adhesions – iatrogenic repeated intraarticular steroid injections prolonged immobilization – degenerative—primary osteoarthritis ClassificationClassification ofof PatellofemoralPatellofemoral DisordersDisorders Trauma (conditions caused by trauma in otherwise normal knee) – acute trauma contusion fracture – patella – femoral trochlea – proximal tibial epiphysis (tubercle) dislocation (rare in normal knee) rupture – quadriceps tendon – patellar tendon – repetitive trauma (overuse syndromes) patellar tendinitis (“jumper's knee”) quadriceps tendinitis peripatellar tendinitis (e.g., anterior knee pain in adolescent caused by hamstring contracture) prepatellar bursitis (“housemaid's knee”) apophysitis – Osgood-Schlatter disease – Sinding-Larsen-Johansson disease – late effects of trauma posttraumatic chondromalacia patellae Figure 48-10 Patellofemoral joint posttraumatic patellofemoral arthritis anterior fat pad syndrome (posttraumatic fibrosis) viewed from superolateral portal; reflex sympathetic dystrophy of patella patellar osseous dystrophy lateral subluxation of patella is evident. acquired patella infera acquired quadriceps fibrosis Patellofemoral dysplasia – lateral patellar compression syndrome secondary chondromalacia patellae secondary patellofemoral arthritis – chronic subluxation of patella secondary chondromalacia patellae secondary patellofemoral arthritis – recurrent dislocation of patella associated fractures – osteochondral (intraarticular) – avulsion (extraarticular) secondary chondromalacia patellae secondary patellofemoral arthritis – chronic dislocation of patella congenital acquired Idiopathic chondromalacia patellae Osteochondritis dissecans – patella – femoral trochlea Figure 48-11 Grade III Synovial plicae (anatomical variant made symptomatic by acute or repetitive trauma) – medial patellar (“shelf”) chondromalacia of patella involving – suprapatellar – lateral patellar central ridge and lateral facet.

Surgical Guidelines for Patients Who Have Not Responded to Vigorous, Appropriate Conservative Treatment for Patellofemoral Pain LATERAL RELEASE Consistent tenderness and tightness in lateral retinaculum (extraarticular lidocaine injection can be tried first in tender area) usually associated with patellar tilt or subluxation. Painful arthrosis in patellofemoral joint with roentgenographically documented lateral patellar tilt and minimal or no subluxation. In association with realignment of patella for chronic lateral subluxation or dislocation but not as isolated procedure for realignment (unless future CT studies show significant relief of subluxation after lateral release). Persistent patellofemoral pain and lateral traction osteophyte at lateral retinacular insertion into patella. PROXIMAL (SOFT TISSUE) REALIGNMENT Skeletally immature with history of recurrent patellar dislocation. Skeletally immature or mature with persistent patellofemoral pain and elevated congruence angle with or without significant patellar tilt and unresponsive to vigorous, appropriate rehabilitation program. Minimal or nonexistent arthrosis. Dysplastic femoral trochlea and evidence of poor medial patellar support by vastus medialis obliquus, causing recurrent patellar subluxation or dislocation. Realignment of patella without diminishing overall patellar contact stress (arthrosis minimal or nonexistent). ANTEROMEDIAL TIBIAL TUBERCLE TRANSFER (Closed physis is prerequisite) Persistent patellofemoral pain related to malalignment with excessive patellar tilt or elevated congruence angle and need for relief of patellar contact stress because of patellar arthrosis. Vastus medialis obliquus advancement may be added as necessary to balance patella in trochlea. Lateral facet arthrosis and elevated quadriceps (Q) angle >22 degrees with patella centered in trochlea. Failed lateral release without evidence of lateral retinacular reattachment and with significant residual lateral tilt. RepairRepair ofof PatellofemoralPatellofemoral InstabilityInstability

Determining Factors Procedure

Lateral pain, lateral tilt, mild lateral Arthroscopic lateral release subluxation, tight lateral structures, Q angle and Insall index within normal limits

Acute dislocation with associated Arthroscope and repair of medial osteochondral fragment or high-level patellofemoral ligament and medial athlete at end of season retinaculum

Recurrence with Insall index <1.2 and Q Modified Elmslie-Trillat lateral release and angle near 20 degrees medial tuberosity transfer; arthroscopic evaluation and medial tuberosity transfer can be done if there is no evidence of lateral tightness Recurrence with Insall index >1.2 Lateral release with distalization and medialization of tibial tuberosity (Simmons procedure)

Recurrence with grade 3 or grade 4 Oblique Fulkerson type leaving chondromalacia at least two thirds of postmedial cortex intact

Recurrence in immature patient Proximal realignment Operative Treatment of Recurrent Subluxation or Dislocation of Patella Operative Procedure Indications Techniques

Lateral retinacular release Recurrent subluxation, relatively normal Q angle Open

Tight lateral structures Arthroscopic

Lateral tilt with minimal lateral subluxation on roentgenogram in combination with realignment procedure Repair of medial Acute or subacute dislocation in association with Open patellofemoral ligament and osteochondral fracture VM Highly competitive athlete near end of season

Proximal extensor Subluxation or dislocation, Q angle <20 degrees Insall, Madigan et al. realignment Distal extensor realignment Recurrent subluxation or dislocation Roux-Goldthwait, Galeazzi Q angle >20 degrees, skeletally immature (soft Elmslie-Trillat tissue realignment) Q angle >20 degrees, skeletally mature

Proximal and distal Recurrent dislocations, skeletally mature, Q angle Hughston, modified realignment approaching 20 degrees Elmslie-Trillat Patellectomy with extensor Skeletally mature, salvage procedure West and Soto-Hall realignment Figure 45-9 Technique of Madigan et al. for proximal realignment of patella. A, Incision. B, Division of tendon of vastus medialis obliquus muscle. C, Synovial relaxing incision. D, Suture of transferred insertion of vastus medialis to patella and quadriceps Figure 45-10 Roux- tendon. Goldthwait operation for recurrent dislocation of patella. Patellar tendon is Figure 45-8 Insall technique of split; lateral half is proximal realignment of transplanted patella. A, Medial and lateral medially. A vasti are separated from preferable procedure rectus femoris tendon. B, would be to transfer Lateral release is performed; medial half of tendon synovium is left intact. C, medially. Completed closure is tight to hold patella securely in femoral groove. D, Remaining medial flap is sutured without further overlap. Figure 45-11 Elmslie-Trillat procedure as modified by Cox. A, Lateral parapatellar incision. B, Superficial and deep Figure 43-153 Maquet incisions of transverse fibers of lateral technique of retinaculum. C, Raised bone attached to advancement of tibial tibia by distal periosteal pedicle. tuberosity by elevation of tibial crest. A, Drill holes and line of osteotomy. B, Osteotomy is sprung open and propped with iliac graft.

Figure 45-12 A, Elmslie-Trillat procedure as modified by Cox. B, Cross section of tibia at level of tibial tuberosity to show bone cuts made to free tuberosity in center and to create new bed for transposed tuberosity to right. C, Cross section of tuberosity fixed with screw in new location anteromedially. Screw should not penetrate posterior cortex. BipartiteBipartite PatellaPatella

Figure 43-150 Ogata technique for bipartite patella. A, Oblique skin incision is made over distal portion of vastus lateralis tendon, extending just distal to midportion of separated area of patella. B, Vastus lateralis tendon is split along its middle fibers and insertion to painful patellar fragment is detached subperiosteally. Continuity of tendon-periosteum complex to main portion of patella is preserved. C, Fragment is relieved from muscle traction without causing a mediolateral imbalance that would affect patellofemoral tracking. Care should be taken not to injure synovial capsule to preserve some blood supply to fragment.

EpiphysitisEpiphysitis ofof TibialTibial TuberosityTuberosity (Osgood(Osgood--SchlatterSchlatter Disease)Disease)

Surgery rarely, simple conservative measures – restriction of activities or cast immobilization for 3 to 6 weeks Patella alta Figure 29-10 Bosworth technique Surgery, symptoms are persistent and for insertion of bone pegs for severely disabling Osgood-Schlatter disease. – tibial sequestrectomy (removal of the fragments) – inserting bone pegs into the tibial tuberosity – excision of the bony prominence through a longitudinal incision in the patellar tendon Complications – subluxations of the patella, patella alta, nonunion of the bony fragment to the tibia, and premature fusion of the anterior part of the epiphysis with resulting genu recurvatum

Figure 29-11 Ferciot and Thomson excision of ununited tibial tuberosity. A, Tibial tuberosity has been exposed.B, Bony prominence has been excised.

OsteochondritisOsteochondritis DissecansDissecans ofof thethe KneeKnee in children with open physes usually heals when treated with cast immobilization preferable to excising the fragment early in life and creating a crater

Figure 29-13 A, Osteochondritis dissecans of medial femoral Figure 29-12 A, Osteochondritis condyle treated with knee immobilizer in 13-year-old child dissecans of medial femoral with physis still open. B, At 3-month follow-up defect condyle in child with open appears to be healing; possible osteochondral loose body physis. B, Four years later, noted. C, At 5-month follow-up patient is asymptomatic with physis is closed and lesion has healed lesion on roentgenogram and a loose body that is healed. asymptomatic.

Figure 43-146 Osteochondritis dissecans of knee, nonoperative treatment. A, Lesion in adolescent treated nonoperatively in cast for 9 months. B, Several years later, complete healing is apparent, and knee is asymptomatic.

Figure 43-145 Sites of lesions of osteochondritis dissecans of knee.

Figure 43-147 Osteochondritis dissecans. A, Osteochondritis dissecans involving weight- bearing portion of lateral femoral condyle in 15-year-old boy. B and C, Fragment internally fixed with multiple Kirschner wires. Figure 29-14 A and B, Large osteochondritis dissecans defect on lateral femoral condyle seen on roentgenogram and magnetic resonance imaging. Chondroblastoma was ruled out in this patient with physes still open. C and D, After 9 months of unsuccessful conservative treatment, arthroscopy and Herbert screw fixation were performed. At the time of arthroscopy lesion was hinged but attached. Procedure requires use of image intensifier for correct guide pin placement and to avoid physis with Herbert screws. E and F, Postoperative anteroposterior and lateral roentgenograms with Herbert screws in acceptable position. Figure 43-148 Algorithm of Clanton and DeLee for treatment of osteochondritis dissecans in symptomatic adult. OsteochondritisOsteochondritis DissecansDissecans ofof thethe PatellaPatella A rare entity affects the subchondral bone and articular surface and the cartilage overlying the surface of the patella An elliptical fragment within a crater, rarely occur bilaterally Frequently painful and quite debilitating Boys between the ages of 10 and 15 are most commonly affected Surgical treatment will not be carried out on an asymptomatic defect MRI Bone scan can help differentiate between the simple, asymptomatic, subchondral defect in the superolateral portion of the patella and OCD of the patella – in OCD of the patella is exceptionally “hot” in comparison to dorsal defects is “cold” Treatment – physes are still open, nonoperative if at all possible restriction of activities and immobilization for a period of time to avoid surgical excision – if conservative treatment fails the lesion can be drilled the lesion can be internally fixed with a small diameter Herbert screw or pins the loose body should be removed and the crater debrided and drilled if the loose body appears to have viable subchondral bone, the crater should be freshened and the loose body placed within the crater and internally fixed Figure 29-16 Osteochondritis dissecans of Figure 29-17 A and B, Roentgenograms of patella. A, Lateral roentgenogram. B, Bone dorsal defect of patella in superolateral scan. C and D, MRI revealing quadrant. C and D, Magnetic resonance imaging osteocartilaginous fragment including revealing dorsal defect of patella with cystic articular cartilage within crater. defect noted but not involving the articular cartilage. SnappingSnapping SyndromesSyndromes ofof thethe KneeKnee Rare, more commonly in the hip, shoulder, or True “snapping” – extraarticular – abnormal anterior insertion of the biceps femoris tendon on the fibular head – snapping popliteus tendon syndrome - between the lateral epicondyle and the lateral joint line – abnormal insertion of the semitendinosus tendon – a hamstring tendon sliding over an osteochondroma of the femur Intraarticular “catching” or “locking” – meniscal tears, loose bodies, patellofemoral disorders, or arthritic joint changes JumperJumper’’ss KneeKnee ((TendinitisTendinitis ofof thethe ExtensorExtensor MechanismMechanism ))

Tendoosseous junction at the inferior pole of the patella Repetitive traction or overload injury during sports – prolonged, repetitive microtrauma causes focal mucoid degeneration, fraying, and microtearing of the collagen fibrils – occasionally, a single episode of eccentric overload or a direct blow to the tendon Tenderness at the inferior pole of the patella – associated abnormalities of patellar tracking, chondromalacia, Osgood-Schlatter disease, or mechanical malalignment of the leg – radiolucency and elongation of the involved pole early in the process – periosteal reaction of the anterior patellar surface (“tooth sign”) and tendon calcification – stress fracture or disruption of the extensor Figure 46-33 Elongation mechanism of lower pole of patella in Conservative treatment tennis player with long history of patellar Surgical treatment tendinitis. FourFour StagesStages ofof JumperJumper’’ss KneeKnee <> Phase 1 pain only after activity Phase 2 pain during and after activity but no significant functional impairment Phase 3 pain during and after activities with progressive difficulty in satisfactory performance

Phase 4 Figure 46-34 Stress fracture of inferior pole of patella in end-stage disease with stress collegiate basketball player. fracture through the patella or Fracture is secured with disruption of the extensor parallel screws; corticocancellous slot graft is mechanism placed distally across fracture. SynovialSynovial LesionsLesions Pigmented villonodular synovitis (PVNS) Synovial (osteo)chondromatosis

FIGURE 3. (A) There were hundreds of brilliant white, cartilagelike loose bodies and a few bodies adhering to the hypertrophic synovium, which was excised (arrows). (B) Histological examination shows cartilaginous synovial metaplasia FIGURE 2. Loose bodies accumulate in the (A) with synovial hypertrophy (arrows). The medial compartment and (B) lateral gutter. No disorganized chondrocytes were loose bodies remain in the (C) medial and (D) surrounded by a thin fibrin layer (H&E, lateral compartments original magnification 100). Figure 113-18 Synovial osteochondromatosis of the knee with narrowing of the joint space and multiple large, calcified bodies filling the joint space and suprapatellar pouch.

Figure 48-12 A, Localized nodular synovitis of posteromedial compartment of knee. B, Arthroscopic excision of localized nodular synovitis with arthroscope in posteromedial portal and probe through intercondylar notch to palpate posterior cruciate ligament. Synovial attachment of nodular synovitis is just superior and posterior to probe. NormalNormal vsvs OAOA JointJoint

NormalNormal kneeknee OsteoarthriticOsteoarthritic kneeknee ThickenedThickened capsulecapsule CapsuleCapsule CystCyst formationformation

SclerosisSclerosis inin Cartilage Cartilage subchondralsubchondral bonebone

Fibrillated cartilage SynoviumSynovium Fibrillated cartilage SynovialSynovial hypertrophyhypertrophy

BoneBone OsteophyteOsteophyte formationformation OsteoarthritisOsteoarthritis (OA)(OA)

Primary osteoarthritis – polyarticular – rarely occurs before the age of 35 years – especially in weightdegenerative arthritis of unknown origin obese patients over the age of 50 years Secondary osteoarthritis – monarticular -bearing , more common in – mechanical derangement, Figure 25-8 In anomaly, osteoarthritis of and fracture into a joint are among the common causes knee varus or The prognosisphyseal is better for the primary type, valgus polyarticular degenerativeseparation, arthritis,pyogenic than for the deformities secondary type concentrate ligamentousinfection, congenital stress of weight- The progression of primary osteoarthritis is usually bearing in either slower and less relentless instability, medial or lateral An association of osteoarthritis of the hip with part of joint, and occupations requiring heavy lifting and elite sporting degenerative activity, no such relationship between osteoarthritis changes in that of the knee and activity levels part are accelerated. OAOA ofof thethe KneeKnee Result of mechanical and biological events that destabilize the normal processes of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone Include increased water content, decreased proteoglycan content, and altered collagen matrix, all leading to the deterioration of articular cartilage Radiographs – nonuniform joint space narrowing – cortical sclerosis on the weight- bearing bony surfaces – subchondral cyst – marginal osteophytes – loose bodies and subluxation Treatment – conservative – surgical TreatmentsTreatments ofof thethe OAOA KneeKnee

Debridement Osteochondral and autologous chondrocyte transplantation Proximal (high) tibial osteotomy – close or open wedge, medial or lateral – dome Distal femoral osteotomy – unicompartmental knee arthroplasty – total knee arthroplasty DistalDistal FemoralFemoral OsteotomyOsteotomy

Figure 25-24 Supracondylar V osteotomy for correction of valgus Figure 25-23 Coventry technique of deformity. A, Because of shape of lower femoral osteotomy. Angle to medial femur, minor shortening of be corrected is measured on cortex of proximal fragment (x) preoperative roentgenogram, and produces sufficient narrowing (y) to nail of blade plate is driven into allow cancellous penetration on medial femoral metaphysis so that plate side with no lateral openings or will accomplish desired correction translation (B). C, No wedges are taken, when attached to osteotomized and minimal bone removal is required. femoral shaft. Wedge with apical angle equal to amount of correction is removed with osteotomy. HighHigh TibialTibial OsteotomyOsteotomy (Dome(Dome--shaped)shaped)

Figure 25-18 Barrel-vault osteotomy of Maquet uses special jigs to properly orient dome osteotomy. Distal tibia can be translated if needed. HighHigh TibialTibial OsteotomyOsteotomy (Wedge(Wedge--shaped)shaped)

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Figure 25-19 Medial opening wedge tibial osteotomy. A, Osteotomy proximal to tibial tubercle begins 3.5 cm distal to medial joint line and is directed toward proximal tip of fibula, leaving lateral part of cortex intact. B, Osteotomy is pried open, and wedge-shaped bicortical iliac bone grafts are inserted. Osteotomy is < open > fixed with plate and screws. Figure 25-13 Fixation of valgus osteotomy of proximal tibia by staples just anterior to fibula. Figure 25-16 A, Medial joint collapse resulting in varus deformity and medial knee pain. B, After high tibial osteotomy.

Figure 25-14 Fixation of valgus osteotomy of proximal tibia by lateral contoured T-plate.

RARA ofof thethe KneeKnee

Characteristics Etiology Clinical feature Radiologic feature – periarticular soft tissue swelling – juxtaarticular osteoporosis – marginal erosion and cyst – uniform loss of joint space – marked deformity with subluxation, dislocation, destruction, and fusion Pathological feature Management – conservative – surgical

PrepatellarPrepatellar BursitisBursitis

Traumatic prepatellar bursitis – an acute injury, such as a fall directly on the patella; recurrent minor injuries, such as “housemaid's knee” – conservative treatment – excision of the bursa if fibrosis or synovial thickening with painful nodules fails to respond to such treatment Pyogenic prepatellar bursitis – common, especially in children – unusually large – a careful physical examination – often responds to one or two daily aspirations, appropriate Figure 24-8 Multiple bursae around immobilization, and antibiotic knee that may become acutely or coverage chronically inflamed. – not significantly improved in 36 to 48 hours, incision and drainage PoplitealPopliteal CystCyst (Baker(Baker Cyst)Cyst) Baker in 1877 (Adams in 1840) Bursa beneath the medial head of the gastrocnemius or in the semimembranosus bursa; the latter is a double bursa located between the semimembranosus tendon and the medial tibial condyle and between the semimembranosus tendon and the medial head of the gastrocnemius either by herniation of the synovial membrane through the posterior part of the capsule of the knee or by the escape of fluid through the normal communication of a bursa with the knee, that is, either the semimembranosus or the medial gastrocnemius bursa In children – the cyst infrequently communicates with the joint, and intraarticular pathological findings are rare – simple excision usually are excellent even if incomplete, Figure 24-11 Removal generally resolve with benign neglect, aspiration may be attempted provided the diagnosis is certain of midline Baker cyst. In adults A, Skin incision. B, After being exposed, – intraarticular pathological findings are common, such as patellofemoral chondromalacia or a degenerative tear of the pedicle is clamped, posterior horn of the medial meniscus ligated, divided, and – recur if the intraarticular pathological condition is not inverted. corrected – If the cyst does not appear to communicate or if significant changes cannot be treated arthroscopically, an open procedure is indicated TibiaTibia VaraVara (Blount(Blount Disease)Disease)

Erlacher (1922) the first description of tibia vara and internal tibial torsion Blount's article (1937) described tibia vara as “an osteochondrosis similar to coxa plana and Madelung's deformity but located at the medial side of the proximal tibial epiphysis” An acquired disease of the proximal tibial metaphysis, rather than an epiphyseal dysplasia or osteochondrosis Cause unknown ? – infection ? – trauma ? – avascular necrosis ? – a latent form of rickets ? a combination of hereditary and developmental factors is the most likely cause Weight-bearing, early walking and obesity Clinical and roentgenographic findings are varus and internal torsion of the tibia and genu recurvatum TwoTwo TypesTypes ofof TibiaTibia VaraVara

Infantile, begins before 8 years of age – difficult to differentiate from physiological bowing, especially before the age of 2 years – infantile tibia vara is bilateral and symmetrical in approximately 60% of affected children, increases progressively – physiological bowing is almost always bilateral, tends to resolve with growth Adolescent, begins after 8 years of age but before skeletal maturity – an adolescent form between the ages of 8 and 13 years caused by partial closure of the physis after trauma or infection – “late-onset” tibia vara in obese children, especially black children, between the ages of 8 and 13, without a distinct cause histological changes are markedly similar to infantile tibia vara or slipped capital femoral epiphysis asymmetrical compressive shear forces across the proximal tibial physis promote disruption and cause compression and deviation of normal intercondylar ossification TibiaTibia VaraVara (Blount(Blount Disease)Disease)

Medial half of the epiphysis on roentgenograms – short, thin, and wedged Physis – irregular in contour and slopes medially Proximal metaphysis – forms a projection medially (often palpable), but not diagnostic Medial metaphyseal fragmentation – pathognomonic for the development of a progressive tibia vara Angular deformity Figure 29-39 Diagram of – just distal to the projection roentgenographic changes seen Stage VI in infantile type of tibia vara and – the medial portion of the epiphysis fuses their development with at a 90-degree downward angle increasing age. TreatmentTreatment ofof BlountBlount DiseaseDisease Depends on – the age of the child – the severity of the varus deformity Observation or a trial of bracing Figure 29-44 Severe Blount disease. A, Closing wedge metaphyseal osteotomy. B, – between the ages of 2 and Epiphyseal elevation. 5 years Osteotomy – progressive deformity Recurrence of the deformity is not as frequent after osteotomy at an early age Figure 29-45 Hemicondylar osteotomy.