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At Least It’s Not Your ACLObjectives

• Review anatomy of the knee

• Identify tendon injuries around the knee

• Discuss management of patella fracture and dislocation

• Review post-op management of the injured knee

Types of Knee Injuries

• Ligament Injuries

• ACL, PCL, MCL and LCL

• Bony Injuries

• Cartilage injuries

• Meniscus and Articular Cartilage

• Tendon Injuries

• Quad tendon and Patellar tendon

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Patella Fractures

Mechanism of Injury• 1% of all fractures

• Usually the result of a direct blow or fall

• Most are transverse fractures

• Men twice as likely as women

• Most require surgery

Diagnosis of Patella Fracture• Anterior knee pain

• Swelling

• Inability to straight leg lift

• Defect in the patella

• X-ray confirmation

Treatment Options

Non surgical

• Cast

• Brace

• Crutches

Surgical

• ORIF with screws

• Tension Band

• Partial patellectomy

• Total patellectomy

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Post-op Management

• Admit for pain control

• WBAT with crutches

• Knee brace

• Ice for comfort

• Shower 3 days

• Stitches out 10-14 days

Rehabilitation

• Based on injury and repair performed

• Straight leg raise at 1 week

• Passive ROM at 3 weeks

• Resistive exercises at 6 weeks

• Brace for support for 3 months

• Partial patellectomy held for 4 weeks to allow soft tissue healing

Patella Instability

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Patella Instability

• Generic TermA) Patella dislocation

B) Patella subluxation

• Affects between 7-49/100,00

• 11% of musculoskeletal symptoms seen in office

• 16 – 25% of all injuries in running

• Higher incidence in females

A) BONY

• Patella

• Femur (Trochlea)

B) SOFT TISSUE

1. Medial Retinaculum

2. Quads (VMO)

3. MPFL

Anatomy

Stability in Motion

EARLY FLEXION• Distal patellar engages superior aspect trochlear

groove• Quads are dynamic stabilizer • MPFL 1° static soft tissue restraint • ˃ 50% of medial restraint forces in cadaver study • ↑Flexion contact area of patella moves proximally

MID FLEXION 90°

• Proximal pole contacts distal aspect

trochlear groove

• Deeply engaged in groove

• ↑ Flexion causes contact with MFC/ medial

facet patella and LFC with lateral facet

PAST 90° FLEXION

• Smaller third facet engages MFC

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THE STAR OF

OUR SHOW

MPFL

MPFL

• Inserts sup/medial border of patella 6

mm below superior pole

• Origin - entire length of medial femoral

epicondyle

• Average length 5 and 6 cm

• Insertion broader than origin

• Also sends branches to VMO / Medial

retinaculum

Classification of Patellar

Instability

• Congenital

• Traumatic

• Developmental

ETIOLOGY

• Multifactorial

Can be traumatic from direct blow

• Developmental as a result of patella alta and

dysplasia

• Delayed engagement in shallow trochlea

• Tibial tubercle placement

HISTORY

• Anterior knee pain

• Giving way, going out

• Determine if specific event

• What previous treatment?

Successful?

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EXAM:

Inspect

• Bruising

• Swelling

Palpate

• Medial facet

• Lateral femoral condyle

• Thorough leg exam

٭ MCL

٭ Mimic ACL (history)

• Moving Patella Apprehension Test

MOVING PATELLAR APPREHENSION TEST

Knee 20 – 30° flexion

• Lateral pressure on patella

• ↑ bend, may ↑ apprehension = positive test

• Repeat with medial direction pressure

better = positive test

Q ANGLE

• Angle between ASIS and Patellar Tendon

• Males 8 - 10°

• Females 15 - 20°

Factors that ↑ Q Angle

• External tibial torsion

• Laterally positioned TT

• Genu valgum

• ↑ Femoral anteversion

PATELLAR TILT TEST

• Patient supine, knee flexed 20°

• Attempt to elevate lateral facet by pushing down

medially

• Elevation to less than neutral means tight lateral

tissue

• 0-20° Elevation is normal

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• X-Rays - Fleck of Bone medially

• CT scan • TT – TG - 90° - TT ˂20mm lateral to mid trochlea

of femur

• MRI• Bone contusion LFC

• MPFL tear

• Articular damage

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COLLATERAL DAMAGE !

CT SCAN with FRACTURE

TREATMENT

- Non-Surgical

- Surgical

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NON-SURGICAL TREATMENT

• PT is often successful

• Initially focus on VMO strengthening

• Stretching also important

٭ Achilles

٭ Hamstrings / Quads

٭ IT Band

٭ LAT Retinaculum

• Closed chain exercises

• Core stability

• Functional Alignment

• Braces, orthotics for pronation, taping

Surgical Treatment

Proximal Realignment

Distal Realignment

Trochleoplasty

SURGICAL CONSIDERATION

• Patient Age

• Level of Activity

• Condition of Joint

• Origin of Deficiency

- May be combination of alignment and soft tissue injury

PROXIMAL REPAIR AND

REALIGNMENT

• Repair ligament at point of injury

• Anchors used to fix ligament to femur or patella

• Recommended:

• 1) In chronic case with failed conservative Rx

• 2) Acute Instability with loose chondral fragment

• If combining with TT transfers; do transfer first, then tension

ligament

Reconstruction of MPFL

• Not for pain, arthritis, or to correct malalignment

• Do not over tighten; leads to more pain and arthritis

Procedure for MPFL

• Scope knee• Harvest graft • Place tunnels in patella• Secure graft to patella• Tension graft • Fix graft to femur

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MEDIAL IMBRICATION AND VMO

ADVANCEMENT

• First described procedure was huge

• Large lateral release

• Large lateral advancement

• Mini open with small lateral release proved more reliable

• Can now medially imbricate with scope

• Mention of lateral release

• Never isolated procedure

DISTAL REALIGNMENT

• Abnormal trochlea or patella alta

• Transfers tibial tubercle distally and medially

• Corrects Q-Angle

• TT / TG Index corrected

• Good results 89 – 93%

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Lift tubercle and shift medially

TROCHLEOPLASTY

• 1ST Described in 1915

• Modified over the years

• Results in arthritis

SUMMARY

Restore normal mechanics

Intact but attenuated MPFL – Imbrication

Reconstruct MPFL

• MPFL and retinaculum attenuated

• Congenital Dislocation

• Severe ligamentous laxity

Large Q Angle / Trochlea Dysplasia

Tibial tubercle transfer

Lateral release never isolated procedure

Cartilage Injury

• Meniscus Tears

• Articular Cartilage Injuries

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Mechanism of Injury

• Trauma

• Ligament / Fractures

• Twisting

• Squatting

Symptoms / Exam

• Intra – articular swelling

• Pain on joint line

• Lock / loss of extension

• Pain with McMurray’s

• Int/ext rotation of tibia

Knee X-Ray MRI Showing A Meniscus

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Treatment• Arthroscopy

• Debridement

• Repair

Meniscal Repair

• Location of tear critical

• White on red

• Red on red

Return to Sports

•Resect – 10 to 14 days

•Repair – 4 to 6 months

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Osteochondritis Dissecans

Definition

•Condition in Which Portion of Subchondral Bone Undergoes Partial or Complete Separation From Its Bony Bed

•Males/Females – 2/1

•Trauma Or Vascular Origin

Osteochondritis Dissecans (OCD)

Mechanism of Injury

- Lesion is Pre-Existing

- Twisting Injury Dislodges Piece

Osteochondritis Dissecans

Physical Exam

- Pain

- Swelling

- Locking Sensation, Popping

- Loose Body

Osteochondritis Dissecans

Radiology

•X-ray to Assess Location, Number of Fragment

•MRI Useful to Measure, Size, Depth, Condition of Articular Surface

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Osteochondritis Dissecans

Treatment

Postop

•NWB 6 to 8 weeks

•Gradual Return to WB Over 3 weeks

•Serial X-rays to Determine

Incorporation

•Return to Sports – 4 to 6 months

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Tendon Ruptures

Overview

- Quadriceps Tendon

- Patellar Tendon

Quad Tendon Rupture

Method of Injury

•Eccentric Contraction of Quad (i.e.

Recovering From Tripping)

•Rupture Intrasubstance or From Proximal

Pole Patella

•Increase Risk with D.M., Gout, Chronic

Steroids, Dialysis

Quad Tendon Rupture

Physical Exam

•Immediate Severe Pain and Swelling

•Persistent Buckling, Cannot Climbs

Stairs

•Palpable Defect

•Complete Tear – Cannot SLR

Incomplete – Extensor Lag

Quad Tendon Rupture

Radiology

•Low Patella, Patella Baja

•Avulsion Fracture

•Soft Tissue Swelling

•MRI Will Show Tear, Used in

Equivocal Cases

Quad Tendon Rupture

Treatment

•Rarely Non-Surgical

•Majority Require Surgery

•Slow Return to Full Motion

•Return to Sports 6 to 9 months

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Patella Tendon Rupture

Mechanism of Injury

•Similar to Quad Tendon

•Also Seen in Jumping Sports

•Bilateral Ruptures Seen in

Patients With Systemic Diseases

Patella Tendon Rupture

Physical Exam

•Defect Below Patella

•Cannot Extend Leg Actively

•Severe Pain, Inability to Walk

Patella Tendon Rupture

Radiology

•X-rays Reveal Patella Alta,

High Riding Patella

•MRI Only For Equivocal Cases or

Suspicion of Other Injuries

Patella Tendon Rupture

Treatment

•Incomplete Tear Rare, Could Immobilize

4 to 6 weeks

•Majority Require Surgery

•Auxiliary Wire to Protect Repair

•Begin Motion 3 Weeks Postop

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Patellar Tendon Rehabilitation

• Straight leg brace at discharge

• WBAT with crutches

• May begin early motion if good repair and auxiliary wire used

• Usually do not return to full sports activity for 6-9 months

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