Knee patho (PF and ottawa)- Dr. Davies

Question 1

Ottawa Knee Rules (what is the point)

Answer 1

why do you need a radiograph

a negative result on an Ottawa Knee Rule test accurately excluded knee fx after an acute knee injury

acute knee injury- only about 7% have fracture

Question 2

Ottawa Knee Rules (details on the studies)

Answer 2

N=4249
Sen= 98.5%, Spec= 48.5%
*quite a bit of research on this starting back in 1995, done on thousands of patients
*the final one was a systematic review on the guidelines, when to use and when not to use a radiograph

Question 3

Ottawa Knee Rule (type of knee injuries)

Answer 3

most knee injuries results from a direct blow, fall, or twisting injury
Blows and falls are referred to as a macrotrauma or “blunt injury” and account for 25% of knee injuries (80% of all fractures)

Question 4

finding a fracture in a blunt injury versus a twisting injury

Answer 4

finding a fracture is 4 times more likely after a blunt injury than after a twisting injury

Question 5

Ottawa Knee Rule (5 yes or no)

Answer 5

1) age 55 years or older
2) isolated tenderness of patella (no bone tenderness of knee other than patella)
3) tenderness at head of fibula
4) inability to flex knee past 90*
5) inability to bear weight both immediately and in an ER for 4 steps (unable to transfer weight twice onto each lower limb regardless of limping)

Question 6

why do you need a radiograph in adults over the age of 55?

Answer 6

osteoporosis, etc occurs more in older adults

Question 7

tenderness on the patella (Ottawa Knee Rules)

Answer 7

usually secondary to landing on the patella if they fall or if something hit them directly; direct marcotrauma

Question 8

tenderness over the head of the fibula (Ottawa Knee Rules)

Answer 8

occurs when there is a direct macrotraumic injury to the head of the fibula

Question 9

which Ottawa Knee Rule does Dr. Davies not agree with

Answer 9

not being able to bend the knee past 90*
there are a lot other injuries (ACL, PCL, meniscus, etc) that can cause the knees to not want to bend past 90 (from a twisting injury)

Question 10

Ottawa Knee Rules (practical application)

Answer 10

patient’s preference and point of view might influence the use of the Ottawa Knee Rules in clinical practice

Question 11

what are the first two parts of the body parts to “go”

Answer 11

the low back is first to “go” then the knees

Question 12

Patellar Femeral Pain Syndrome (other names)

Answer 12

(PFPS)
(AKPS) anterior knee pain syndrome
the black box of orthopedics
the mysterious syndrome 
*so many different possibilities, yet the most common in the knee*

Question 13

How to grade the patella

Answer 13

grade on a quadrant system
the patella is sitting in the center of the femoral sulcus; will push the patella out of the sulcus and grade the subluxation; grade 2 is normal
(grade 1 is hypo, grade 3 is hyper)
*testing the superficial fibers of the retinaculum

Question 14

measuring a tilt of the patella

Answer 14

measuring the deep fibers of the retinaculum
a line through the medial and lateral epicondyles; will tilt the patella; the tilt is defined as the direction towards the femur (so the medial tilt will test the lateral deep fibers)
15* is normal

Question 15

how to treat PFPS

Answer 15

the key to treating patients with PFPS is to treat the CAUSE and not just the SYMPTOMS

Question 16

Sun Rise View

Answer 16

the x ray beam is at different angles to see the patella in the femoral trochlea (there are different types of views that are dictated by the doctor, Skyline view, etc)

Question 17

which is higher: lateral or medial femoral condyle in relation to the patella

Answer 17

the lateral side should always be higher, it should acts as a boney buttress

Question 18

Lateral Trochlear Dysplasia

Answer 18

when the lateral trochlea is the same high as the media

Question 19

measurements on the sunrise view

Answer 19

TT: tibial tuberosity
TG: trochlear groove

Question 20

Q angle

Answer 20

where you measure from the ASIS to the mid patella to the tibial tuberosity
it measures the pull of quadriceps at the knee
~valgus vector- 5-10 for males, 10-15 for females

Question 21

Patella Alta

Answer 21

(grasshopper eyes)
found by the Insall-Salvati Ratio on a lateral radiograph; patient is standing and measure the tibial tuberosity to the inferior pole of the patella and inferior to the superior pole of patella; should be 1:1 ratio (.2 is the standard deviation)
unstable patella

Question 22

Squinting Patellas

Answer 22

can be with Patella Alta or Baja;

patellas are inward

Question 23

Patella Infera (Baja)

Answer 23

smaller Install-Salavati Ratio

more OA changes

Question 24

Fabella

Answer 24

boney growth in the lateral head of the gastro

Question 25

Bayonet Sign (knee)

Answer 25

squinting knee that has the proximal external tibal deformity; makes the leg look like a bayonet genu varum

Question 26

Camel Sign (knee)

Answer 26

two humps when looking at the lateral view of the knee | patella is one hump and the second hump is the intrapatella fat pads

Question 27

Miserable Malalignment Syndrome

Answer 27

1) Femoral anteversion 2) Squinting patellas 3) Proximal tibial torsion 4) Distal tibial verum 5) STJ pronation

Question 28

PF biomechanics

Answer 28

lateral vector- VMO and medial rect in the medial diction; lateral rect, IT band, and vactus lateralis *want the patella to go in a straight line or in a straight line with a slight medial in the center and back to the center

Question 29

Chondromalacia

Answer 29

DONT USE IT unless the doctor has it documented on a surgical note

Question 30

Classification of Patella Dislocation (2)

Answer 30

LAACS and TONES | *know that Fulkerson is the person that wrote the article

Question 31

LAACS

Answer 31

L: laxity, generalized and lower- aged at initial dislocation A: atraumatic in nature A: abnormal patella femoral architecture and abnormal ligamentous laxity C: chronic in nature; contra lateral involvement S: sex dependent with greater number of females

Question 32

TONES

Answer 32

T: traumatic, sports related MOI O: older at initial dislocation, OCD fracture more common N: normal PF architecture, normal alignment E: equal sex distribution S: single occurrence, single leg involvement

Question 33

PF Classifications

Answer 33

``` Patellar compression syndrome Patellar instability Biomechanical dysfunction Direct patellar trauma Soft tissue lesion Overuse syndrome Osteochondritis disease Neurological disorder *Hoffa's Syndrome ```

Question 34

Hoffa's Syndrome

Answer 34

pain in the infrapatellar fat pad

Question 35

Dye's research

Answer 35

he scoped his knee without anesthesia to rate the pain in different parts of the knee 2 parts of the research: pain and general/ localized worst pain was in the infrapatellar fat pad

Question 36

Other terms for Surgical Shortening

Answer 36

``` Plication Imbrication Reefing "Vest Over Pants" Capsulorraphy ```

Question 37

Proximal Realignments

Answer 37

Lateral Release VMO Advancement/ Reefing MPFL-R

Question 38

Lateral Release | about

Answer 38

done when the lateral side it too tight or the medial side is too loose Usually the tight lateral retinaculum

Question 39

Lateral Release | surgery

Answer 39

go in and cut the lateral retinaculum up to the VL will allow the patella to be correctly aligned from the lateral tilt and/or glide into the sulcus *want the scarring to occur in the stretched position

Question 40

Lateral Release | Complication

Answer 40

when there is a lateral release, a complication is cutting the superior lateral genicular artery, which leads to a lot of effusion *try and cauterize it to minimize the bleeding, but it still seems to bleed a lot during this surgery

Question 41

Why do they do a VMO Advancement?

Answer 41

since they just loosen the lateral side with a lateral release, it would make sense to tighten the medial side

Question 42

VMO Advancement | what is it

Answer 42

Shorten the medial side because it was all stretched out | put the patella back in the correct location and then tighten the VMO to keep the patella in the correct alignment

Question 43

MPFL (what does it stand for)

Answer 43

Medial Patella Femoral Ligament

Question 44

MPFL (what does it do)

Answer 44

this is the primary stabilizer for the patella

Question 45

MPFL (surgery)

Answer 45

gracilis tendon (auto graft) or allograft can drill all the way to the other side or make a "V" or put suture anchors into it do something to tighten it *this is the number one *surgery for PF stabilization now a fully torn will need surgery

Question 46

Distal Realignment Procedures

Answer 46

Hauser Elmslie Trillat Fulkerson's Anteromedialization Maquet

Question 47

MPFL-R

Answer 47

medial patella femoral ligament- reconstruction

Question 48

Hauser Procedure

Answer 48

an older procedure (don't even worry about it, isn't used any more); created more problems then helped

Question 49

Elmslie Trillat Procedure

Answer 49

moves the tibial tuberosity medial; take the tibial tuberosity and osteotomize (cut it off) and slide it medially wont see many of these any more

Question 50

Fulkerson's Anteromedalization

Answer 50

only moves the tibial tuberosity medial a little bit *don't take it as far medially or distally; wont let it go too far medially sometimes do this with the proximal realignment procedures

Question 51

Marquet Procedure

Answer 51

elevates the tibial tuberosity try to minimize the pressure in the PF joint (PF joint reaction forces) put a bone plug in there to elevate and decrease the pressure

Question 52

Elmslie Trillat Procedure (Problems)

Answer 52

Problem- it ended up more on the side then in the center | if you take too far medially/ distally, you can create a patella Baja; it was counter productive

Question 53

Trochleoplasty

Answer 53

(not commonly done in the US; more done over in Europe) | they carve out the femoral trochlea so that the patella will track better

Question 54

Other Rehab for PF

Answer 54

taping, bracing, VMO activation,

Question 55

MPFL rehab Protocols

Answer 55

``` two different: 1) 0-90 in one day or 2) progressive increase in ROM weekly week 1: 0 week 2: 0-30 week 3: 0-45 week 4: 0- 60 week 5: 0-75 week 6: 0-90 *depends on the doc ```

Question 56

Biomechanical Considerations in Patellofemoral Joint Rehabilitation (how the graph is set up)

Answer 56

the patellofemoral joint reaction forces ROM on the x axis: 0 is full extension pressure per unit contact of the patella in the sulcus is the y-axis *solid circles is full closed kinetic chain motions (squat) *open circles is open kinetic chain

Question 57

Biomechanical Considerations in Patellofemoral Joint Rehabilitation (what the graph means)

Answer 57

when in CKC- extension has very little stress on the knee and starts to increase as the when in OKC- start at 0* and the pressure decreases as it gets to 90* (pressure is higher per contact surface at 0* than near 90*)

Question 58

Biomechanical Considerations in Patellofemoral Joint Rehabilitation (how to apply this in the clinic)

Answer 58

you have a patient with PF pain. have the patient doing squats (CKC) from 0-45* and doing OKC from 90-45* because there is less pain if there is even more pain in a patient- CKC from 0-30* and OKC from 90-60* (these are short arc, which have a 20* overflow) ***will be on the exam**