Transcript Deformities of the knee

Deformities of the knee



Genu varus (medial angulations)
Genu valgus (lateral deviation)
Genu recurvatum (hyperextended
knee )
Objectives:
1.
2.
3.
Define variable angular deformities
of the knee joint and discuss its
etiology.
Describe a clinical method for
diagnosis, follow up and prognosis
of genu varus and valgus.
Discuss the management and
indication of surgical intervention.
Developmental knee
deformities.
Genu varus (bow leg).
Genu valgus (knock knee);
During early years of life (before
10 years) these deformities can
be regarded as normal stages
of development & must be
followed up frequently .
Follow up is by:
the intercondylar distance
for varus
 the intermalullar distance
for valgus

Normal intercondylar distance is
less than (6cm), if its (6-8cm) it
needs frequent follow up, if
more than (8cm) it needs
surgical correction.
Normal intermalullar distance is
less than (8cm), if its (8-10cm) it
needs follow up, if more than
(10cm) its indication for surgery.
Other indications for surgery
includes:
1.
2.
3.
4.
5.
6.
Severe deformity.
Unilateral deformity.
Rapidly progressive deformity.
If uncorrected deformity after the
age of (l0-12) years.
Painful deformity.
Deformity associated with joint
instability or derangement.
Secondary causes of angular
deformities:
1.
2.
3.
4.
Rickets; causing bone softening and
progressive deformities with weigh
bearing.
Post-traumatic; with epiphysial injury &
arrest, malunion or with joint ligament
injury.
In adults it commonly occurs with
osteoarthritis (varus knee), or with
rheumatoid arthritis (valgus knee).
Other diseases like Paget’s disease
(varus knee).
Management:
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
Frequent clinical assessment
needed to look for progression &
indication for surgery.
Take x-ray for the knee & tibia to see
the state of the epiphysis & state of
the deformity.
For patient near skeletal
maturity (1-2 years) of maturity
we can use stapling (internal
fixation with staples) of the
upper tibial & lower femoral
epiphysial plates at the side of
overgrowth to allow other side
to grow & correct the deformity.
If the above procedure is not
applicable we do corrective
osteotomy and we should avoid
injuring the nearby epiphysis;
for varus deformity we do high
tibial osteotomy, & for valgus
deformity we do supracondylar
femoral osteotomy.
Genu recurvatum:
Possible causes:

Congenital; by abnormal
intrauterine posture.
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Ligament laxity; either congenital &
generalized or secondary to injury,
infection, over traction or muscle
weakness as in polio.
recurvatum
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Secondary to fixed equinus deformity
of
the foot in which the patient
hyperextend the knee to put the foot
flat in the ground.
Following growth plate injury.
Malunited fractures.
Treatment:

When indicated corrective
osteotomy of the tibia or femur is
done. Other operation is excision of
the patella & fix it on the upper tibia
to act as a bone block to prevent
hyperextension of the knee.
Summary:
1.
2.
3.
4.
5.
6.
Normal knee is at 5-7 degrees of valgus, anything less is
genu varus, anything more is genu valgus and any
abnormal hyperextension is genu recurvatum.
Causes can be developmental, congenital or secondary
acquired.
For genu varus we examine the intercondylar distance, for
valgus we examine the intermalullar distance its good for
the diagnosis, follow up and prognosis of genu varus and
valgus.
Developmental varus and valgus may improve during the
development and bone remodeling up to the age of 9-10
years, if it didn’t correct this indicates surgical intervention.
Most secondary angular deformities may need treatment of
the primary cause and surgical operation.
Surgery may be in the form of epiphysial growth arrest
(stappling) or by osteotomy.
Meniscal diseases of
the knee
Objectives:
1.
2.
3.
4.
5.
Discuss the surgical pathology, functions,
mechanisms of meniscal injuries and variable
types of meniscal tears.
Describe the clinical presentation differential
diagnosis and investigations of meniscal
injuries.
Discuss the methods of treatment of acute and
chronic meniscal tears.
Define meniscal cyst and describe its clinical
presentation, differential diagnosis and
investigations.
Discuss the treatment of meniscal cyst.
Pathology & mechanism of
injury:
Medial meniscus is more commonly
involved in injury because:
1. It’s larger in size.
2. It’s more fixed to the tibia &
capsule.
3. Its more commonly involved in
serious joint strains & activities.
Functions of the menisci:
1.
2.
3.
4.
5.
Improve range of motion.
Better distribution of the synovial
fluid inside the joint.
Act as a shock absorber.
Improves joint stability.
Sterioseption as they contain
special nerve endings.
Mechanism of injury:
Is that the medial meniscus get
grinded between the femur & tibia
when the flexed loaded knee get
twisted causing meniscal tear which
most commonly seen in young adults
& athletes specially footballers.
Types of meniscal tears:

75% of the tears are vertical tears;
most common type is that which
involve the middle part of the
meniscus but does not reach the
periphery,possible displacement
gives the bucket handle tear, which
is the most common cause of locking
of the knee joint in meniscal tears.
•Other vertical tears may reach the
center causing anterior or posterior
horn tear.
•Less common tears are the horizontal
tears that most commonly occurs in
degenerated stiff meniscus of older
people.
Clinical features:

The patient usually young adult
footballer had history of severe
twisting injury of the knee followed
by severe knee pain & inability to
complete the game.
•
Knee swelling & effusion occurs
after several hours to 24 hours from the
time of injury, but never occurs
immediately (as in heamarthrosis).
•
There is limitation of knee
movements, mainly knee extension
i.e. locking of the knee, which means
failure of the last degrees of extension
(its mechanical locking by the effect of
the displaced bucket handle tear of the
meniscus).
•
Few days later effusion subsides &
the knee may spontaneously unlock,
while the pain is still mild and takes
longer to disappear. Always there is
severe quadriceps wasting.
•
Chronic frequent knee pain and
effusion may occur later on after milder
twisting injury during work or games,
sometimes frequent locking &
givingway.
Investigations:
1.
2.
3.
X-ray; to exclude associated
fracture.
Arthroscopy; it’s the best to give
direct visualization of the inside of
the joint to prove the diagnosis &
exclude other possible injuries.
MRI; good and accurate
noninvasive technique specially if
associated with arthroscopic
findings.
Differential diagnosis:
1.
2.
3.
4.
5.
Lose bodies; they cause pain and locking
that occurs at different degrees of knee
movement (change in the position of
locking) at each time.
Patellofemoral instability; with frequent
knee pain & givingway.
Fracture of tibial spine.
Rupture of anterior cruciate ligament
(ACL).
Partial tear of medial collateral ligament
with tender medial femoral condyle at
the site of attachment.
Treatment:

Arthroscopy can prove the
diagnosis & show the site & type of
the tear. Conservative treatment
is only indicated for peripheral tears
where the vascular meniscus may
heal if the knee is rested for 3-4
weeks in POP or if the meniscus is
sutured.
•Otherwise operative treatment is always
indicated by arthroscopy, the aim is to
excise the torn part of the meniscus only &
leave the remaining intact part to avoid later
degenerative changes of the knee.
• Always remember the
possible associated injuries as
ACL tear, fractures or synovial
damage and heamarthrosis.
Prognosis:

Neither meniscal tears by itself
nor removal of the meniscus
necessarily leads to secondary
osteoarthritis, but it’s the general
state of the knee, its stability and
the possible associated injuries that
matter.
Meniscal cyst:
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It’s a multiloculated cystic swelling that
contains gelatinous fluid & surrounded by
fibrous tissue, it occurs between the
meniscus (usually the lateral) & the
capsule.
it shows as a localized swelling below the
joint line its more prominent at certain
degrees of knee flexion (65 degrees) &
decrease in size at other positions of the
knee.
Causes:
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Synovial implantation theory in
which following trauma or
embryonic synovial cells implants in
the vascular area of meniscus &
grow as a cyst.
Secondary to horizontal tear of the
lateral meniscus.
Clinical features:
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It usually appears at the lateral side
of the knee just below the joint line
anterior to the collateral ligament.
It shows as a painful aching lump
that gets larger in certain
movements and may disappear in
others.
Differential diagnosis:
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Ganglion; its more superficial,
softer & above or below the joint
line.
Calcified deposit of the collateral
ligament.
Prolapsed torn meniscus.
Various tumors as; lipoma, fibrorna
or osteochondrorna.
Treatment:
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Always do arthroscopy to exclude
intraarticular lesions as meniscal tear
which when treated may lead to
decompression of the cyst from
within.
Otherwise we do surgical excision of
the cyst.
Summary:
1.
2.
3.
4.
5.
6.
The medial meniscus is more prone to injury than the lateral, the
outer third of meniscus is vascular and the remaining is not, it serves
variable functions including increasing the range of motion and knee
stability.
Commonest type of tears are the longitudinal (bucket handle or horn
tear), the meniscus usually torn when the loaded knee is flexed and
twisted.
Clinically torn meniscus presents as pain and later swelling with
possible locking, chronic complaint is by recurrence of symptoms at a
milder knee twist.
Arthroscopy is the best for diagnosis as well as for the treatment by
partial excision of the torn part of the meniscus or menical sutre for
peripheral tears.
Meniscal cyst is uncommon and mostly lateral it presents as local
swelling and may due to a meniscal tear.
Meniscal cyst needs arthroscopy to diagnose and treat associated
meniscal pathology. Otherwise surgical excision of the cyst is done.
Chronic ligamentous instability:
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Untreated ACL or collateral ligament
tears may cause chronic joint instability
with variable symptoms, functional
disturbances & possible later
osteoarthritis.
Those patients needs good clinical &
arthroscopic assessment, together with
intensive course of physiotherapy &
muscle strengthening exercises (including
the quadriceps & hamstring groups) all to
improve joint stability & function.
Whenever there is associated
meniscal tear it must be surgically
treated to improve symptoms &
allow physiotherapy.
Otherwise if conservative
treatment is not useful, surgical
reconstruction of the torn
ligament is done by using
certain structures as fascia lata
or surrounding tendons
Patellofemoral Diseases
Objectives:
1.
Declare variable patellar functions and the
factors that prevents patella from dislocation as
well as main cause of patellar dislocation.
2.
3.
4.
Discuss in details the common recurrent patellar
dislocation, mechanism, clinical presentation,
emergency treatment and variable surgical
options of its treatment.
Define patellofemoral overload syndrome, its
clinical presentation, diagnostic tests,
investigations and differential diagnosis.
Discuss the main lines of its management, nonsurgical and operative choices.
Patellofemoral instability:
Patella have different functions that
includes:

Protection of the knee on kneeling.

Improvement of knee function &
range of motion.

Prevent direct friction of extensor
mechanism with the femur.
Knee is normally in 5-7
degrees of valgus therefore
quadriceps pull may cause
lateral subluxation or dislocation
of patella, this does not occur
because:
1.There is large & high lateral
femoral condyle.
2.Tight extensor retinaculum
that prevents displacement.
3. Direct medial pull of patella
by the lower horizontal fibers of
the vastus medialis, which has
direct attachment to the patella.
predisposing factorsfor lateral
dislocation of patella:
1.
2.
3.
4.
5.
Congenitally abnormal patella (cong
.high or small patella).
Abnormally small lateral femoral
condyle.
Valgus knee.
Generalized ligament laxity.
Primary muscle defect.
Types of patellar dislocation:
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Post-traumatic dislocation
(previously discussed).
Non-traumatic dislocations;
• Congenital dislocation.
• Recurrent dislocation.
• Habitual dislocation.
Congenital patellar dislocation:
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Its rare & severe form associated
with abnormal soft tissue attachment
& sometimes with knee dislocation.
Treated by different procedures of
soft tissue reconstruction but the
results are unpredictable.
Habitual dislocation of the
patella:
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In this type the patella dislocates every
time the knee is flexed & relocates in
extension.
It’s possibly caused by Q-contracture
(vastus lateralis) either congenital or
secondary to early childhood injection.
Treatment:
By division of the contracted bands of
vastus lateralis, iliotibial band rectus
femoris & V-Y plasty of the Q-tendon.
Recurrent patellar
dislocation:

It’s the most common type usually
occurs in adolescent girls & mostly
bilateral.
Mechanism and clinical features:

It occurs when sudden Q-contraction is
taken to extend the flexed knee, The
patella dislocates laterally with a click &
this will cause severe pain, patient is
unable to extend his flexed knee & fall
down. Sometimes the knee relocates on
certain movements as the patient try to
straighten his flexed knee.
Mechanism and clinical features:
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When dislocated there is prominent
medial femoral condyle that sometimes
mistaken for the patella.
Tenderness on the medial side of the
joint and heamarthrosis will occur.
In chronic cases there is medial
retinacular laxity & apprehension test is
positive.
X-ray:
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
Plain x-ray
CT scan with extended knee
Treatment
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At the time of dislocation reduction
by MUA with aspiration of
heamarthrosis & back-slap for 3
weeks. Followed by of physiotherapy
& Q-exercises especially vastus
medialis.
If this fails or dislocation is
frequently recurrent, operative
treatment is indicated
these operations are:
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Lateral release +/- medial reaf of the
ext. retinaculum .
Camblell-roux operation, to induce
medial displacement of the tendon &
patella, all associated with lateral
release & medial reaf.
Goldthwait operation. it can improve
medial pull of the patella.
Hauser operation.
All operations followed by good schedule
of physiotherapy & Q-exercises.
Patellofemoral overload
syndrome; Patellar pain
syndrome or Chondromalacia
patellae:
All are names for the same
clinical syndrome of anterior
knee pain & Patellofemoral
tenderness, usually associated
with softening & fibrillation of the
patellar articular cartilage
(Chondromalacia patellae). It’s
more common in adolescents &
young adults.
Pathology & pathogenesis:

The problem is mainly a form of
overstressed Patellofemoral joint
with repeated injury of patellar
articular cartilage; this mostly
because of malcongrousy or
malaligenment of Patellofemoral joint
leading to a sequence of changes in
cartilage & bone.
Clinical features:
anterior knee pain
 occasional swelling
 givingway
usually bilateral

On examination
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the knee looks normal
Q-wasting
tenderness on the under surface of
the patella.
Mild effusion
abnormal patellar tracking &
subluxation or even crepitus can be
noticed.
Apprehension test sometimes
positive.
Specific test is the grinding
test
Imaging:
X-ray of the knee may show
abnormal patella or femur.
 Special view is the skyline
view
 CT scan with extended knee
is best

Arthroscopy:

it can show cartilage
changes but it’s most
important to exclude other
causes of knee pain.
Differential diagnosis:
1.
2.
3.
4.
5.
6.
Overuse in athletes.
PF-instability.
Patellar cyst or tumor.
Prepatellar bursitis.
Osteochondritis dissecans.
Torn meniscus.
Treatment:
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
1st. Conservative treatment
2nd. Surgical treatment:
It’s indicated if conservative
treatment fails after 6 months
use, it aims at control of
malcongrousy & malaligenment
of the PF-Joint &decrease PFpressure.
these operations are:
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Lateral retinacular release +/- medial
reaf
Hauser operation.
Distal elevation of the patella by
using a bone block to elevate the
tibial tubrosity.
Chondroplasty by shaving the
cartilage.
Patellectomy for severe resistant
cases that does not respond to other
possible
Summary:
1.
Patella is important for proper extensor knee mechanism , it
increases knee range of motion and specially important on
taking the stairs and running.
2.
3.
4.
5.
6.
The large lateral femoral condyle and the tight extensor
retinaculum around it and the direct attachement of the
transverse lower fibers of vastus medialis – all – keeps patella in
position.
Patella dislocates if its small or high or if there is small lateral
condyle or any abnormality of the bone or soft tissue that makes
the the patella pushed laterally like valgus or external rotation of
the leg.
recurant pat. Dislocation is the most common type usually occurs
in adolescent girls & mostly bilateral, It occurs when sudden Qcontraction is taken to extend the flexed knee.
Pain tenderness on the medial side of the joint and heamarthrosis
occurs in acute dislocation. In chronic cases there is medial
retinacular laxity & apprehension test is positive.
urgent reduction is easy and treatment of recurance directed
towards treatment of the cause if there is one, and all are aiming
at medialization of the pull of the extensor mechanism.
Summary:
1.
2.
3.
4.
patellofemoral overload syndrome is a clinical syndrome
of anterior knee pain & Patellofemoral tenderness, usually
associated with softening of the patellar articular
cartilage, It’s more common in adolescents & young
adults and due to friction or over stress through the PFJ.
presentation is anterior knee pain, sometimes history of
instability. Pain aggravated by activity, climbing upstairs,
or when standing after prolonged rest (theater sign).
swelling & givingway may occur & symptoms can be
bilateral.
On examination Q-wasting, tenderness on the under
surface of the patella, abnormal patellar tracking or
crepitus can be noticed. Apprehension test and Grinding
test sometimes positive.
treatment usually nonoperative and surgery reserved for
resistant case and are mostly like those for instability.
Miscellaneous knee
problems
Osteochondritis
dissecans (splitting
O.ch. of the knee):
its suggested to be caused
by repeated trauma by the edge
of the patella on full flexion that
occurs on the lateral aspect of
the medial femoral condyle
(this site accounts for more than
80% of all cases).
The disease pass in three stages:
1.
2.
3.
Avascular nonseperated segment
with intact overlying cartilage.
Detached Undisplaced segment.
Displaced segment, either
incomplete or complete where it
acts like a loose body leaving an
ulcer called crater that later get
fibrosed.
Clinical features:


Adolescent patient mainly
males 15-20 years of age, it can
be bilateral & may run in
families.
There is intermittent pain,
swelling, givingway & locking
together with muscle wasting.
Diagnostic features are:
1.
2.
Tenderness on medial femoral
condyle.
Positive Wilson’s test; with the
knee flexed we try internal rotation
& gradual extension; this will
induce medial condyle pain which
get relieved on external rotation.
Diagnosis
X-ray:
It’s helpful at later stages.
While isotope scanning and
MRI can diagnose it earlier.
 Arthroscopy: can prove
diagnosis & sometimes used
for treatment.

Differential diagnosis:
1.
2.
Avascular necrosis of the
medial fernoral condyle that
occurs in older alcoholics or in
steroid abuse, it affect the
dome of the condyle & is more
extensive.
Osteochondral fracture of the
femoral codyle.
Treatment

In early stages the lesion
is stable, here restriction of
activities with the use of
caliper or crutch for 6-12
months is useful and no need
for other treatment, intimate
follow up & MRI of the other
knee is indicated.
Treatment
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
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At later stages & if the
fragment is small it can be
removed.
If its more than one
centimeter & not detached we fix
the fragment in position.
If the fragment is detached
with unhealthy crater, it’s
removed & the crater is drilled to
allow healing with fibrocartilage.
Synovial
chondromatosis
Synovial chondromatosis

Rare disorder in which the
tips of the synovial sheath
undergoes cartilaginous
metaplasia & later detaches
as a free cartilaginous loose
bodies
Clinical features:

Chronic swelling,
givingway, locking & pain
are common.
X-ray: it may show loose
bodies.
Arthroscopy: can prove the
diagnosis (snowstorm
appearance).
Treatment:

By athrotomy or arthroscopy,
all those loose bodies must
be washed out and removed
& the abnormal synovium is
excised (synovectomy).
Loose bodies inside
the knee
1.
2.
3.
4.
5.
Causes:
Post-traumatic osteochondral
fracture.
Fractured ostephytes in cases of
osteoarthritis of the knee joint.
Osteochondritis dissecans.
Synovial chondromatosis.
Charcot’s (neuropathic) joint.
Clinically they cause aches,
swelling, locking & givingway.
Diagnosis by X-ray, MRI, and
arthroscopy.
Treatment by removal of the
loose bodies & treatment of the
cause.
Swelling of the knee
joint
1st. heamarthrosis: by;
1.
2.

Hemophilic arthropathy.
Post-traumatic by;
a. Intraarticular fracture
b. Rupture of ACL or capsule.
c. Rupture or damage of the
synovial membrane.
Clinical features, diagnosis &
treatment all according to the
cause.
2nd. Acute septic arthritis:


Causes, pathology, C/F,
investigations, differential diagnosis
& treatment all are previously
discussed.
Special point is that sometimesrepeated aspiration by wide bore
needle or cannula & trocher is used
in the knee together with saline
irrigation, all under antibiotic cover.
If this fails we still can do open
arthrotomy and drainage.
3rd. Acute post-traumatic
synovitis:

Synovial fluid collects few
hours after injury or in the
next day, this is associated
with Q-wasting & painful
limitation of movements.
Sometimes it needs
aspiration & resting the joint
in POP.
4th. Acute non-traumatic
synovitis:

Acute swelling without trauma or
infection suggests crystal
deposition disease as Gout or
Pseudogout; this may need
aspiration & biochemical study.
5th. Chronic knee swelling: as
with;
1.
2.
3.
4.
5.
Tuberculosis.
Rheumatoid arthritis.
Osteoarthritis.
Pigmented villonodular
synovitis.
Charcot’s disease
(neuropathic joint).
Osteoarthritis of the knee (OA):

Knee is commonly involved
by OA, which can be
secondary or most commonly
primary OA that usually
affect people after 5Oyears
and mostly occurs bilaterally.
Clinical features: Special
features include;



Bow legs (Genu varus) its very
common.
Pain on varus or valgus stress of
the knee in the affected joint
compartment
On knee movement PF-crepitus
may be reproduced.
X-ray:
1.
2.
3.
All previously mentioned
cardinal features are seen
with special features like;
Features mostly seen in the
medial compartment.
There is varus alignment
between tibia & femur.
Picture better seen in the
standing films.
Treatment:
Conservative
treatment?
 Operative
treatment

Operative treatment
1.
2.
3.
Arthroscopic washout; to decompress
the joint &wash the proteolytic enzymes
& loose bodies.
Patellectomy.
Realignment osteotomy; to correct
varus deformity we do wedge resection
valgus osteotomy of the upper tibia, this
acts by
• Redistribution of weight towards more
healthy areas of the articular cartilage.
• Venous decompression to decrease
pain.
• Correct deformity.
Operative treatment
4. Replacement arthroplasty.
5. Arthrodesis.
Swellings around the
knee joint:
1)
2)
3)
4)
5)
Prepatellar bursitis
Infrapatellar bursitis
Semimembranosus
bursa
Popletial cyst
Popletial-artery
aneurysm.
Swellings around the
knee joint:
Meniscal cyst.
7) Ganglion.
8) Calcified deposits of
collateral ligament.
9) Prolapsed torn meniscus.
10) Tumors like; lipoma,
fibroma or
osteochondroma.
6)
Prepatellar bursitis;

There is inflammation of the bursa
between the skin & the patella, the
condition
called house-made
knee. The joint is normal but there is
swelling of the bursa sometimes its
tender, it may need aspiration &
steroid injection or sometimes
surgical excision. Always exclude
rheumatoid & gouty arthritis.
Infrapatellar bursitis;

It’s inflammation of the
bursa between the skin & the
patellar ligament, its also
called clergyman’s knee.
Semimembranosus bursa;

Swelling of the bursa between the
semi-membranosus tendon & the
medial head of gastrocnemious
muscle appears as a painless
swelling on the posteromedial aspect
of the knee, its fluctuant & gets
larger when the knee is straight and
decrease or disappear as the knee is
flexed. If it’s symptomatic it needs
surgical excision.
Popletial cyst (backer’s cyst):

It’s a type of synovial fluid filled cystic
swelling herniates posteriorly from the
knee joint, its most common in OA of the
knee and also in some cases of
rheumatoid arthritis. Its painless fluctuant
& at the level of the joint it does not
affected by the knee movements.
Treatment, always treat the cause
specially OA as by high tibial osteotomy,
which usually lead to cyst regression.
Sometimes we do aspiration & local
steroid injection or surgical excision of the
cyst but those procedures usually
associated with recurrence of the cystic
swelling.