Orthopedics Knee

Question 1

Normal Anatomy Knee

Answer 1

Question 2

Physical Exam

• Both knees appear _______.
• Sw______ /Effusions?
• ________ to palpation?
• ROM (~0 - ____); patellar motion / instability
• Distal ______vascular exam (no different than hip)
• _______: Anterior/Posterior/Va____/Va____ - +definition?

Answer 2

• Both knees appear symmetric.
• Swelling / Effusions?
• Tenderness to palpation?
• ROM (~0 - 120); patellar motion / instability
• Distal neurovascular exam (no different than hip)
• Stability: Anterior/Posterior/Varus/Valgus

Question 3

Common Conditions

(3)

Conditions 1 slide each

(7)

Answer 3

1. Patellofemoral syndrome / chondromalacia patella / patellar instability
2. Meniscal tears
3. Degenerative joint disease / Arthritis (huge category of diagnoses!)
   
   • Inflammatory v. noninflammatory…(outside the scope of this lecture)
4. Ligament injuries
5. Septic arthritis (can be any joint…)
6. Patellar tendon rupture
7. Quadriceps tendon rupture
8. Patellar fracture
9. Pes anserine bursitis
10. Osgood-Schlatter

Question 4

Patellofemoral syndrome / chondromalacia patella / patellar instability

=

_______ common, especially in ad______ and _____adults (____ > ____ gender)

• Can be idiopathic (i.e. no _______) with or without changes in the articular cartilage (1)
• Can be a result of patellar ___stability
• Diagnosis → ______ knee pain, ______ with kneeling, squatting, prolonged sitting, stairs, patellar compression
• Treatment
  
  • ​In general, responds very well to directed _______ / ______ceps strengthening
  • Surgery reserved for significant anatomic mal______ or severe in______ only
• Some consider these conditions a precursor of patellofemoral ________

Answer 4

Anterior Knee pain

Extremely common, especially in adolescents and young adults (women > men)

• Can be idiopathic (i.e. no instability) with or without changes in the articular cartilage (chondromalacia)
• Can be a result of patellar instability
• Diagnosis → anterior knee pain, worse with kneeling, squatting, prolonged sitting, stairs, patellar compression
• Treatment
  
  • In general, responds very well to directed exercises / quadriceps strengthening
  • Surgery reserved for significant anatomic malalignment or severe instability only
• Some consider these conditions a precursor of patellofemoral arthritis

Question 5

Patellofemoral Syndrome History and Symptoms

• Diffuse _____ in the ______ of the knee (major symptom)
• ______ onset and typically v_____ in nature
• Aggravated by specific daily activities including
  
  • C_____ or descending st____
  • Prolonged sitting with knee ____ (known as “______ sign”)
  • S______ or kneeling
• Cr_______ / Mechanical symptoms (anteriorly)

Answer 5

• Diffuse pain in the anterior of the knee (major symptom)
• Gradual onset and typically vague in nature
• Aggravated by specific daily activities including
  
  • Climbing or descending stairs
  • Prolonged sitting with knee bent (known as “theatre sign”)
  • squatting or kneeling
• Crepitus / Mechanical symptoms (anteriorly)

Question 6

Patellofemoral Syndrome PE

• Pain with com______ of patella with knee range of motion or resisted knee _______
• Signs of patellar _____
• Lateral ______ of patella in extension, _______ in flexion (compare motion to contralateral side)
• Positive patellar __________ test (discomfort with ______ force)

Answer 6

• Pain with compression of patella with knee range of motion or resisted knee extension
• Signs of patellar instability
• Lateral subluxation of patella in extension, reduces in flexion (compare motion to contralateral side)
• Positive patellar apprehension test (discomfort with lateral force)

Question 7

Patellofemoral Syndrome Imaging

• XR:
  
  • Recommended views: AP, ____ral, S_____
• Look for:
  
  • Lateral patellar t____
  • _______ trochlear groove
  • Signs of PFJ DJD =
  • Keep in mind:
    
    • Even with severe lateral subluxation, the patella reduces with flexion (sunrise view)
    • AP view can be deceiving (positioning / rotation of the x-ray)
• CT / MRI: ______ planning

Answer 7

• XR:
  
  • Recommended views: AP, Lateral, Sunrise
• Look for:
  
  • Lateral patellar tilt
  • Shallow trochlear groove
  • Signs of PFJ DJD = patellofemoral joint degenerative joint disease
  • Keep in mind:
    
    • Even with severe lateral subluxation, the patella reduces with flexion (sunrise view)
    • AP view can be deceiving (positioning / rotation of the x-ray)
• CT / MRI: surgical planning

Question 8

Patellofemoral Conditions Non-Op Treatment

• Mainstay of treatment and should be done for a minimum of one year: R___/ P_/N_____
  
  • NSAIDS are more effective than ______
  • ______ modification
  • Rehabilitation with emphasis on
    
    • V _ _ strengthening
    • _______ strengthening: controversial → externally rotated leg

Answer 8

• Mainstay of treatment and should be done for a minimum of one year: Rest/ PT/NSAIDs
  
  • NSAIDS are more effective than steroids
  • Activity modification
  • Rehabilitation with emphasis on
    
    • Vastus medialis obliquus strengthening
    • Quadriceps strengthening: controversial → externally rotated leg

Question 9

Patellofemoral Conditions Operative Treatment

• Operative
  
  • Very ____ results seen with debridements and “lateral releases”
  • In cases of significant deformity, soft tissue and bony re______ can be done
• When to refer?

Answer 9

• Operative
  
  • Very poor results seen with debridements and “lateral releases”
  • In cases of significant deformity, soft tissue and bony realignments can be done
• Refer
  
  • Symptoms not responsive to NSAIDs, PT, activity modification

Question 10

Meniscal Tears

• Common _____-related injuries in young athletes and can also present as a ______ condition in older patients
• Diagnosis can be suspected clinically with joint ____ tenderness and a positive (1) test, and can be confirmed with (1) imaging.
• Treatment can be nonoperative versus operative ((1) versus (1)) depending on the morphology of the meniscus tear, root involvement, patient symptoms, and patient activity demands.
  
  • Most are treated ______ surgery

NOTE: Degenerative tears are a ______ part of the ______ process, are not separate injuries, and should not be treated in isolation (i.e. almost never MRI; never surgery)

Answer 10

• Common sports-related injuries in young athletes and can also present as a degenerative condition in older patients
• Diagnosis can be suspected clinically with joint line tenderness and a positive McMurray’s test, and can be confirmed with MRI imaging.
• Treatment can be nonoperative versus operative (partial meniscectomy versus repair) depending on the morphology of the meniscus tear, root involvement, patient symptoms, and patient activity demands.
  
  • Most are treated without surgery

NOTE: Degenerative tears are a normal part of the arthritis process, are not separate injuries, and should not be treated in isolation (i.e. almost never MRI; never surgery)

Question 11

Meniscal Tears History and Symptoms

• Pain localized to m_____ or l____ joint _____
• Mechanical symptoms (l_____ and cl______), especially with f_____ / squatting
• Intermittent sw_______

Answer 11

• Pain localized to medial or lateral joint line
• Mechanical symptoms (locking and clicking), especially with flexion / squatting
• Intermittent swelling

Question 12

Meniscal Tears Physical Exam

• Joint _____ tenderness (most sensitive physical examination finding)
• Eff_____

Provocative tests

1. (1) Prone-flexion compression
2. ​(1) standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking
3. (1) flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
   
   • a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.

Answer 12

• Joint line tenderness (most sensitive physical examination finding)
• Effusion

Provocative tests

1. Apley Compression: Prone-flexion compression
2. ​Thessaly Test standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking
3. McMurray’s Test flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
   
   • a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.

Question 13

Meniscal Tears Imaging

• XR:
  
  • Should be _____ in young patients with an acute meniscal injury
    
    • Meniscal ________ may be seen in crystalline arthropathy
• (1)
  
  • Most ______ diagnostic test but also high false positive rate
    
    • “Over-calls” it…
  • Look for _____ signal on the T2s
    
    • Joint ______ making its way into the substance of the meniscus

Answer 13

• XR:
  
  • Should be _____ in young patients with an acute meniscal injury
    
    • Meniscal calcifications may be seen in crystalline arthropathy
• MRI:
  
  • Most sensitive diagnostic test but also high false positive rate
    
    • “Over-calls” it…
  • Look for bright signal on the T2s
    
    • Joint fluid making its way into the substance of the meniscus

Question 14

Meniscal Tears Non-Op Treatment

• R___, Rx (1), re________, in_______
  
  • Indications
    
    • Indicated as ______ line treatment for almost all tears
• Outcomes
  
  • Improvement in knee ______ following _ _
  • “Non_____” when compared to arthroscopic partial meniscectomy

Answer 14

• Rest, NSAIDS, rehabilitation, injection
  
  • Indications
    
    • Indicated as first line treatment for almost all tears
• Outcomes
  
  • Improvement in knee function following physical therapy
  • “Noninferior” when compared to arthroscopic partial meniscectomy

Question 15

Meniscal Tears Operative Treatment

Indicatated when?

(2) options

Answer 15

Persistent painful mechanical symptoms that correspond with the anatomic location of the tear

Debridement vs. Repair

Question 16

Degenerative Joint Disease/Arthritis

• ________ disease of the knee joint that causes progressive ____ of articular ________.
• Diagnosis can be made with plain (1) of the knee. (advanced imaging is not typically helpful)
• Treatment is observation, NSAIDs, tr_____ and cortico______ for minimally symptomatic patients. Knee (1) is indicated for progressive symptoms with severe degenerative disease.
• The most common types of arthritis are (2), but there are more than 100 different forms.
  
  • I will focus on osteoarthritis

Answer 16

• Degenerative disease of the knee joint that causes progressive loss of articular cartilage.
• Diagnosis can be made with plain radiographs of the knee. (advanced imaging is not typically helpful)
• Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. Knee arthroplasty is indicated for progressive symptoms with severe degenerative disease.
• The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms.
  
  • I will focus on osteoarthritis

Question 17

Degenerative Joint Disease/Arthritis History and Symptoms

• A__, f_______ activity, p______ of arthritic involvement, overall health and du_____ of symptoms
• Function-limiting knee _____
  
  • l_____ walking distances
• Activity induced sw_____
• Knee s____ness
• Mechanical symptoms → more cr_____ than what is seen with meniscal tears

Answer 17

• Age, functional activity, pattern of arthritic involvement, overall health and duration of symptoms
• Function-limiting knee pain
  
  • limited walking distances
• Activity induced swelling
• Knee stiffness
• Mechanical symptoms → more crepitus than what is seen with meniscal tears

Question 18

Degenerative Joint Disease/Arthritis PE

• Inspection
  
  • Body h______
  • G____ (often protects the affected side)
  • Ef_____?
  • Alignment
    
    • Va___ or Va____?
• Range of motion (compare to _____lateral side)
• ______ exam (stiffness of arthritis usually precludes any significant issues with ligament laxity)

Answer 18

• Inspection
  
  • Body habitus
  • Gait (often protects the affected side)
  • Effusion?
  • Alignment
    
    • Varus or Valgus?
• Range of motion (compare to contralateral side)
• Stability exam (stiffness of arthritis usually precludes any significant issues with ligament laxity)

Question 19

Degenerative Joint Disease/Arthritis Imaging

• XR:
  
  • Recommended views
    
    • Weight-______ views of affected joint
  • Optional views
    
    • S______ view
    • _ _ view in 30 degrees of flexion
  • Look for:
    
    • Joint _____ narrowing
    • Osteo_____
    • Subchondral s______
    • Subchondral c_____
• MRI: ______ the urge, especially in advanced disease

Answer 19

• XR:
  
  • Recommended views
    
    • Weight-bearing views of affected joint
  • Optional views
    
    • Sunrise view
    • PA view in 30 degrees of flexion
  • Look for:
    
    • Joint space narrowing
    • Osteophytes
    • Subchondral sclerosis
    • Subchondral cysts
• MRI: Resist the urge, especially in advanced disease

Question 20

Degenerative Joint Disease/Arthritis Non-Op Treatment

• R___, N_____, _____ilitation, ____tion
  
  • Note on injections:
    
    • ______ is the ______
    • Strong evidence ______ HA injections (e.g. Synvisc, Hyalgan) but most insurance still covers this…
    • Strong evidence against glucosamine/chondroitin

Answer 20

• Rest, NSAIDs, rehabilitation, injection
  
  • Note on injections:
    
    • Cortisone is the mainstay
    • Strong evidence against HA (hyaluronic acid) injections (e.g. Synvisc, Hyalgan) but most insurance still covers this…
    • Strong evidence against glucosamine/chondroitin

Question 21

Degenerative Joint Disease/Arthritis Operative Treatment

• High tibial ______
  
  • Younger patients with isolated medial disease (uncommon)
• ____compartmental arthroplasty (much less common than TKA)
• _____ Knee Arthroplasty
  
  • Approaching 1 million per year in the US!
  • Projected 855% increase by 2050…(will it bankrupt the system!?)

Answer 21

• High tibial osteotomy
  
  • Younger patients with isolated medial disease (uncommon)
• Unicompartmental arthroplasty (much less common than TKA)
• Total Knee Arthroplasty
  
  • Approaching 1 million per year in the US!
  • Projected 855% increase by 2050…(will it bankrupt the system!?)

Question 22

Surgical Steps

• Meet the patient in the ___-op holding area
• ___ the leg
• N______ and a_____ meets with the patient as well. This is almost always the first (and only) time the patient meets their anesthesiologist
• To OR
• Anesthesia (usually s_____)
• Position (leg t______)
• Prep/drape
• Time-____
• Incision, cut distal ______, cut proximal _____ (both perpendicular to the mechanical axis of the leg, either using mechanical jigs or computer navigation).

Answer 22

• Meet the patient in the pre-op holding area
• Mark the leg
• Nursing and anesthesia meets with the patient as well. This is almost always the first (and only) time the patient meets their anesthesiologist
• To OR
• Anesthesia (usually spinal)
• Position (leg tourniquet)
• Prep/drape
• Time-out
• Incision, cut distal femur, cut proximal tibia (both perpendicular to the mechanical axis of the leg, either using mechanical jigs or computer navigation).

Question 23

Finishing Cuts, Trials

• St______ in flexion, extension, midflexion
• Full extension, flexion to ~____ degrees
  
  • Regardless _____ ROM is best predictor of post-op…
• Remove trials
• Wash
• Ce_____ in real components
• Wash
• Close
• R_____ room

Answer 23

• Stability in flexion, extension, midflexion
• Full extension, flexion to ~120
  
  • Regardless pre-op ROM is best predictor of post-op…
• Remove trials
• Wash
• Cement in real components
• Wash
• Close
• Recovery room

Question 24

Other Knee Conditions (1 slide each)

(7)

Answer 24

1. Ligament injuries
2. Septic arthritis (can be any joint…)
3. Patellar tendon rupture
4. Quadriceps tendon rupture
5. Patellar fracture
6. Pes anserine bursitis
7. Osgood-Schlatter

Question 25

Knee Ligament Injuries ## Footnote * Goal here is to highlight that there are 4 main ligaments of the knee: * (ACL) = * (PCL) = * (MCL) = * (LCL) = * To test them: * _____ → ACL * _______ → PCL * V\_\_\_\_\_→ MCL * V\_\_\_\_\_\_ → LCL

Answer 25

* Goal here is to highlight that there are 4 main ligaments of the knee: * Anterior Cruciate Ligament (ACL) * Posterior Cruciate Ligament (PCL) * Medial Collateral ligament (MCL) * Lateral Collateral ligament (LCL) * To test them: * Anterior → ACL * Posterior → PCL * Varus → MCL * Valgus → LCL

Question 26

Septic Arthritis ## Footnote * **Inflammation of the joints secondary to an ______ etiology** * Diagnosis is made with an ______ of joint fluid with a ____ count of ________ **being considered diagnostic for septic arthritis.** * Lower counts may still indicate infection in the presence of _____ gram stains or cultures results. * Treatment is usually urgent surgical (1) followed by culture directed (1). * Can be any joint, but knee represents ~\_\_\_% of cases * Then hip, shoulder, elbow, ankle, sternoclavicular joint

Answer 26

* **Inflammation of the joints secondary to an infectious etiology** * Diagnosis is made with an aspiration of joint fluid with a WBC count **50,000 being considered diagnostic for septic arthritis.** * Lower counts may still indicate infection in the presence of positive gram stains or cultures results. * Treatment is usually urgent surgical irrigation and debridement followed by culture directed IV antibiotics. * Can be any joint, but knee represents ~50% of cases * Then hip, shoulder, elbow, ankle, sternoclavicular joint

Question 27

Septic Arthritis ## Footnote * (1) \>50% of cases * (1) ~20% of cases * Most common organism in otherwise healthy sexually active adolescents and young adults * Pain, effusion, warm, unable to bear weight, unable to tolerate passive range of motion * Not always systematically sick * Sometimes...its (1)! * Crystal analysis is diagnostic * BUT...can have septic arthritis in the presence of it as well...

Answer 27

* Staphylococcus aureus, \>50% of cases * Neisseria gonorrhea, ~20% of cases * Most common organism in otherwise healthy sexually active adolescents and young adults * Pain, effusion, warm, unable to bear weight, unable to tolerate passive range of motion * Not always systematically sick * Sometimes...Gout! * Crystal analysis is diagnostic * BUT...can have septic arthritis in the presence of gout as well...

Question 28

Next 3 conditions ## Footnote All disruptors of the ______ mechanism of the knee * Patellar tendon rupture * Quadriceps tendon rupture * Patella fracture

Answer 28

Extension

Question 29

Patellar Tendon Rupture ## Footnote * A tr\_\_\_\_\_\_\_ rupture of the patellar tendon caused by a t\_\_\_\_\_\_ overload during activity in a patient at risk. * Diagnosis can be confirmed by physical exam and radiographs for ______ tears. ______ tears may need an MRI to confirm the diagnosis. * Treatment for complete tears is timely (1) to optimize the chance of healing. Partial tears with an intact extensor mechanism may be treated with (1).

Answer 29

* A traumatic rupture of the patellar tendon caused by a tension overload during activity in a patient at risk. * Diagnosis can be confirmed by physical exam and radiographs for complete tears. Partial tears may need an MRI to confirm the diagnosis. * Treatment for complete tears is timely surgical repair to optimize the chance of healing. Partial tears with an intact extensor mechanism may be treated with immobilization.

Question 30

Patellar Tendon Rupture ## Footnote * Most commonly in ___ and __ decade * Male\_\_ Female * Quadriceps tendon rupture is _____ common than patella tendon rupture (\_:\_ ratio) * _Patella alta_ =

Answer 30

* Most commonly in 3rd and 4th decade * Male \> Female * Quadriceps tendon rupture is more common than patella tendon rupture (2:1 ratio) * _Patella alta_ = *abnormally high patella in relation to femur*

Question 31

Quadriceps Tendon Rupture ## Footnote * A tr\_\_\_\_\_\_ injury of the quadriceps ______ on the patella leading to a disruption in the knee extensor mechanism. * Diagnosis is made clinically with a p\_\_\_\_\_\_ defect __ cm proximal to the superior pole of the patella with inability to perform a (1) test and presence of patella ____ on knee radiographs. * Treatment may be nonoperative in patients with _____ tears and _____ extensor mechanism. Operative repair is indicated if there is disruption of the extensor mechanism.

Answer 31

* A traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. * Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. * Treatment may be nonoperative in patients with partial tears and intact extensor mechanism. Operative repair is indicated if there is disruption of the extensor mechanism.

Question 32

Quadriceps Tendon Rupture ## Footnote * Usually occurs in patients \> ___ years of age * _____ \> ______ (gender) (up to 8:1) * _____ occur with very little or no trauma (esp. diabetics) * Patella \_\_\_\_\_

Answer 32

* Usually occurs in patients \> 40 years of age * Males \> Females (up to 8:1) * Can occur with very little or no trauma (esp. diabetics) * Patella Baja

Question 33

Patella Fracture ## Footnote * Caused by direct tr\_\_\_\_\_ or rapid con\_\_\_\_\_\_ of the quadriceps with a _______ knee that can lead to loss of the extensor mechanism. * Diagnosis can be made clinically with inability to perform a (1) and confirmed with _______ of the knee. * Treatment is either (1) or (1) depending on fracture displacement and integrity of the extensor mechanism.

Answer 33

* Caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism. * Diagnosis can be made clinically with inability to perform a straight leg raise and confirmed with radiographs of the knee. * Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism.

Question 34

Pes Anserine Bursitis ## Footnote * Especially in \_\_\_\_\_\_\_, can be a non-articular cause of knee pain * “G\_\_\_\_\_ Foot” * Sartorius, Gracilis, Semitendinosus (“Say Grace before Tea”) * Inflammation of the bursa located between the shinbone (\_\_\_\_\_) and three tendons of the h\_\_\_\_\_\_\_ muscle at the inside of the knee * Pain and tenderness on the \_\_\_\_side of your knee, approximately 2 to 3 inches _______ the joint * RICE, NSAIDs, PT, Injection

Answer 34

* Especially in athletes, can be a non-articular cause of knee pain * “Goose Foot” * Sartorius, Gracilis, Semitendinosus (“Say Grace before Tea”) * Inflammation of the bursa located between the shinbone (tibia) and three tendons of the hamstring muscle at the inside of the knee * Pain and tenderness on the inside of your knee, approximately 2 to 3 inches below the joint * RICE, NSAIDs, PT, Injection

Question 35

Osgood Schlatter's Disease (Tibial Tubercle Apophysitis) ## Footnote **Osgood-Schlatter disease is osteo\_\_\_\_\_\_\_ or traction _______ of the tibial tubercle, commonly presenting as _______ knee pain in the ________ population.** * **Diagnosis** is made clinically with an _______ tibial tubercle and supplemented with _______ of the knee that reveal \_\_\_regularity and \_\_\_\_\_mentation of the tibial tubercle. * **Treatment** is \_\_\_operative with NSAIDs, activity modification with quadriceps stretching and typically resolves with **physeal closure**

Answer 35

**Osgood-Schlatter disease is osteochondrosis or traction apophysitis of the tibial tubercle, commonly presenting as anterior knee pain in the pediatric population.** * **Diagnosis** is made clinically with an enlarged tibial tubercle and supplemented with radiographs of the knee that reveal irregularity and fragmentation of the tibial tubercle. * **Treatment** is nonoperative with NSAIDs, activity modification with quadriceps stretching and typically resolves with **physeal closure** *Notes: Osteochondrosis = group of disorders that affect the growing skeleton Traction apophysitis = an injury to the cartilage and bony attachments of tendons in children and adolescents*