Disorders of the KneeDisorders of the Knee

PainPainSwelling, effusion or Swelling, effusion or hemarthrosishemarthrosisLimited joint motionLimited joint motion–– pain, stiffness, fluid, pain, stiffness, fluid,

muscular weakness, locking muscular weakness, locking InstabilityInstability–– giving way, laxitygiving way, laxity

DeformityDeformity

Screw home mechanismScrew home mechanism

References:References:1.1. CanaleCanale ST. CampbellST. Campbell’’s operative s operative orthopaedicsorthopaedics. 10. 10thth edition 2003 Mosby, Inc.edition 2003 Mosby, Inc.2.2. Netter FH. The Netter collection of Medical illustrations Netter FH. The Netter collection of Medical illustrations –– musculoskeletal system, Part I & II. musculoskeletal system, Part I & II.

1997 Novartis Pharmaceuticals Corporation.1997 Novartis Pharmaceuticals Corporation.3.3. Magee DJ. Orthopedic Physical assessment. 2nd edition 1992 W. B.Magee DJ. Orthopedic Physical assessment. 2nd edition 1992 W. B. Saunders Company.Saunders Company.4.4. HoppenfeldHoppenfeld S. Physical examination of the spine and extremities. 1976 ApplS. Physical examination of the spine and extremities. 1976 Appletoneton--centurycentury--crofts.crofts.

Anterior Cruciate LigamentAnterior Cruciate Ligament

Tibial insertionTibial insertion–– broad, irregular, diamondbroad, irregular, diamond--shaped area shaped area

located directly in front of the intercondylar located directly in front of the intercondylar eminenceeminence

Femoral attachmentFemoral attachment–– semicircular area on the semicircular area on the posteromedialposteromedial

aspect of the lateral condyleaspect of the lateral condyle33 mm in length33 mm in length11 mm in diameter11 mm in diameterAnteromedial bundle Anteromedial bundle —— tight in flexiontight in flexionPosterolateral bundle Posterolateral bundle —— tight in extensiontight in extension90% type I collagen90% type I collagen10% type III collagen10% type III collagenMiddle Middle geniculategeniculate arteryarteryFat pad (inferior medial & lateral Fat pad (inferior medial & lateral geniculategeniculate arteries)arteries)Primary restraint (85%) to anterior Primary restraint (85%) to anterior translationtranslation

Figure 43Figure 43--24 In addition to their 24 In addition to their synergistic functions, cruciate synergistic functions, cruciate and collateral ligaments exercise and collateral ligaments exercise basic antagonistic function basic antagonistic function during rotation. A, In external during rotation. A, In external rotation it is collateral ligaments rotation it is collateral ligaments that tighten and inhibit excessive that tighten and inhibit excessive rotation by becoming crossed in rotation by becoming crossed in space. B, In neutral rotation none space. B, In neutral rotation none of the four ligaments is under of the four ligaments is under unusual tension. C, In internal unusual tension. C, In internal rotation collateral ligaments rotation collateral ligaments become more vertical and are become more vertical and are more lax, while cruciate more lax, while cruciate ligaments become coiled around ligaments become coiled around each other and come under each other and come under strong tension. strong tension.

Posterior Cruciate LigamentPosterior Cruciate LigamentTibial insertionTibial insertion

–– a a sulcussulcus posteriorly, below the articular posteriorly, below the articular surface of the tibiasurface of the tibia

Femoral attachmentFemoral attachment–– broad halfbroad half--moon or crescent shape moon or crescent shape

anterolaterallyanterolaterally on the medial femoral on the medial femoral condylecondyle

38 mm in length38 mm in length13 mm in diameter13 mm in diameterAnterolateral bundle Anterolateral bundle —— tight in flexiontight in flexionPosteromedialPosteromedial bundle bundle —— tight in extensiontight in extensionAnterior Anterior meniscofemoralmeniscofemoral ligament ligament ((HumphryHumphry))posterior posterior meniscofemoralmeniscofemoral ligament ligament ((WrisbergWrisberg))Middle Middle geniculategeniculate arteryarteryPrimary restraint (95%) against posterior Primary restraint (95%) against posterior tibial displacementtibial displacement

Figure 28Figure 28--AA--2 The four2 The four--bar bar cruciate linkage model. The cruciate linkage model. The model includes two crossed model includes two crossed bars, which represent the bars, which represent the anterior and posterior cruciate anterior and posterior cruciate ligaments (ACL; PCL). The ligaments (ACL; PCL). The remaining two bars represent remaining two bars represent the tibial and femoral the tibial and femoral attachments of the ligaments. attachments of the ligaments. IC, instantaneous center of joint IC, instantaneous center of joint rotation.rotation.

Medial Collateral LigamentMedial Collateral LigamentSuperficial (tibial collateral ligament)Superficial (tibial collateral ligament)–– anterior anterior —— tighten during the first 90tighten during the first 90°° of of

motionmotion–– posterior posterior —— tighten in extensiontighten in extension

Deep (middle capsular ligament)Deep (middle capsular ligament)–– meniscofemoralmeniscofemoral ligamentligament–– meniscotibialmeniscotibial ((conoraryconorary) ligament) ligament

Primary restraint to Primary restraint to valgusvalgus angulationangulation

LCL (Fibular Collateral Ligament)LCL (Fibular Collateral Ligament)Tightest in extension, relax in flexionTightest in extension, relax in flexionPrimary restraint to Primary restraint to varusvarus angulationangulation

PosteolateralPosteolateral Complex (PLC)Complex (PLC)PopliteusPopliteus tendontendonArcuateArcuate complex complex LCLLCL

Figure 43Figure 43--11 Fibers of tibial 11 Fibers of tibial collateral ligament. Points collateral ligament. Points AAand and BB are at anterior border of are at anterior border of long fibers. long fibers. CC is 5 mm is 5 mm posterior to posterior to BB..

Functions of MenisciFunctions of Menisci

Aid in Aid in loadloadtransmissiontransmissionReduce Reduce stressstress on on articular surfacearticular surfaceContribute to joint Contribute to joint stabilitystabilityAid in Aid in lubricationlubricationSupply chondral Supply chondral nutritionnutrition

Medial MeniscusMedial MeniscusPeripheral 20 Peripheral 20 –– 30% vascularized 30% vascularized (medial (medial geniculargenicular artery)artery)More More ““CC”” shapedshaped

Lateral MeniscusLateral MeniscusPeripheral 10 Peripheral 10 –– 25% vascularized 25% vascularized (lateral (lateral geniculargenicular artery), also less artery), also less vascular in the area of vascular in the area of poplitealpoplitealhiatushiatusIncomplete Incomplete ““OO”” shapedshaped

Transverse (Transverse (IntermeniscalIntermeniscal) Ligament) Ligament

Figure 43Figure 43--34 Superior aspect of medial (A) and lateral (B) 34 Superior aspect of medial (A) and lateral (B) menisci after vascular perfusion with India ink and menisci after vascular perfusion with India ink and tissue clearing using modified tissue clearing using modified SpaltheholzSpaltheholz technique. technique. Note Note vascularityvascularity at periphery of meniscus, as well as at at periphery of meniscus, as well as at anterior and posterior horn attachments. Absence of anterior and posterior horn attachments. Absence of peripheral vasculature at posterolateral corner of lateral peripheral vasculature at posterolateral corner of lateral meniscus meniscus (arrow)(arrow) represents area of passage of represents area of passage of poplitealpopliteal tendon.tendon.

Figure 43Figure 43--35 Frontal section of 35 Frontal section of medial compartment of knee. medial compartment of knee. Branching radial vessels from Branching radial vessels from perimeniscal capillary plexus perimeniscal capillary plexus (PCP)(PCP) can be seen penetrating can be seen penetrating peripheral border of medial peripheral border of medial meniscus. meniscus. FF, Femur; , Femur; TT, tibia., tibia.

Meniscal Healing and RepairMeniscal Healing and Repair

History TakingHistory Taking

Physical ExaminationPhysical ExaminationInspectionInspectionPalpationPalpationRange of motion (active & passive)Range of motion (active & passive)NeurologicNeurologic examinationexaminationTests (signs)Tests (signs)Referred painReferred pain

Figure 43Figure 43--25 Movement of femur relative to 25 Movement of femur relative to tibia during flexion, showing contact points tibia during flexion, showing contact points generated by combination of generated by combination of rollingrolling and and glidinggliding. This represents true physiological . This represents true physiological action of action of tibiofemoraltibiofemoral joint.joint.

Figure 28Figure 28--AA--1 Coordinate system for knee joint rotations 1 Coordinate system for knee joint rotations and translations. and translations. FlexionFlexion--extension rotationextension rotation is about the is about the fixed femoral axis. fixed femoral axis. InternalInternal--external rotationexternal rotation is about a fixed is about a fixed tibial axis. tibial axis. AbductionAbduction--adductionadduction is about an axis that is is about an axis that is perpendicular to the femoral and tibial axes. The joint perpendicular to the femoral and tibial axes. The joint translations occur along each of the three coordinate axes.translations occur along each of the three coordinate axes.

InspectionInspectionMalalignmentMalalignment–– genu genu valgumvalgum (knock(knock--knee), knee),

genu genu varumvarum (bowleg), genu (bowleg), genu recuvatumrecuvatum (back knee)(back knee)

Swelling, effusion, skin Swelling, effusion, skin integrity, integrity, ecchymosisecchymosis, , erythemaerythemaPatella positionPatella position–– patella patella altaalta, patella , patella bajabaja, ,

small patella, camel sign, small patella, camel sign, squinting patella, squinting patella, grasshopper or frog eyes grasshopper or frog eyes appearanceappearance

Leg length discrepancy, Leg length discrepancy, deformity (deformity (egeg, pigeon, pigeon--toed foot deformity), gaittoed foot deformity), gait

The The anatomic axisanatomic axis is measured by drawing lines parallel to the long is measured by drawing lines parallel to the long axis of the femur and the tibia and measuring the intercepting aaxis of the femur and the tibia and measuring the intercepting angle.ngle.

The The mechanical axismechanical axis of the leg is measured in the standing position with of the leg is measured in the standing position with an imaginary an imaginary ““plumb lineplumb line”” dropped from the femoral head to the ground.dropped from the femoral head to the ground.

PalpationPalpation

Tenderness Tenderness (location & degree)(location & degree)SwellingSwellingEffusionEffusionDeformity (contour, Deformity (contour, mobility of patella)mobility of patella)Thigh Thigh circumferencecircumference

Tests (Signs)Tests (Signs)

EffusionEffusion–– ballottement (patellar tap), fluctuation, balloon, ballottement (patellar tap), fluctuation, balloon,

brush or strokebrush or stroke

MeniscusMeniscus–– McMurray, Apley compression & distraction, McMurray, Apley compression & distraction,

OO’’DonoghueDonoghue, bounce home, Steinman, modified , bounce home, Steinman, modified HelfetHelfet, , PayrPayr, , BohlerBohler sign, sign, BragardBragard sign, sign, KromerKromersign, Childress sign, Anderson medsign, Childress sign, Anderson med--lateral lateral grind, grind, PasslerPassler rotational grinding, Cabot rotational grinding, Cabot poplitealpopliteal signsign

Tests Tests (Signs)(Signs)Collateral ligamentsCollateral ligaments–– valgusvalgus (abduction) stress, (abduction) stress,

varusvarus (adduction) stress(adduction) stressAnterior instabilityAnterior instability–– LachmanLachman, anterior drawer , anterior drawer

((FinodriettoFinodrietto jumping sign)jumping sign)Posterior instabilityPosterior instability–– posterior posterior ““sagsag”” sign (gravity sign (gravity

drawer), quadriceps drawer), quadriceps contraction, reverse contraction, reverse LachmanLachman, , posterior drawer, Godfrey, posterior drawer, Godfrey, deceleration, disco deceleration, disco ((MerkeMerkesign)sign), leaning hop, one, leaning hop, one--leg hop leg hop

Figure 43Figure 43--44 Abduction stress test.44 Abduction stress test.

Figure 43Figure 43--47 47 Anterior drawer testAnterior drawer test. A, In resting . A, In resting position tibial plateau is held in normal position by position tibial plateau is held in normal position by intact posterior cruciate ligament. B and C, With intact posterior cruciate ligament. B and C, With anterior cruciate insufficiency tibia can be pulled anterior cruciate insufficiency tibia can be pulled forward against force of gravity and tone of flexors.forward against force of gravity and tone of flexors.

Figure 43Figure 43--49 49 LachmanLachman testtest for anterior for anterior cruciate instability.cruciate instability.

Figure 43Figure 43--53 53 ““Posterior drawerPosterior drawer”” often is mistaken for often is mistaken for ““anterior anterior drawerdrawer”” because tibia sags posteriorly and appears to move because tibia sags posteriorly and appears to move abnormal distance forward when examiner tests for anterior abnormal distance forward when examiner tests for anterior drawer phenomenon. A, drawer phenomenon. A, ““Posterior sagPosterior sag”” of right tibia is obvious of right tibia is obvious when compared with normal silhouette of healthy knee joint. B, when compared with normal silhouette of healthy knee joint. B, Tibial sagTibial sag in resting position. If patient starts to raise his foot from in resting position. If patient starts to raise his foot from this position, pull of quadriceps first displaces tibia anteriorthis position, pull of quadriceps first displaces tibia anteriorly into ly into neutral position until anterior cruciate ligament is tight (C). neutral position until anterior cruciate ligament is tight (C). Only Only then is foot raised from table (D). E, Same knee joint as in A nthen is foot raised from table (D). E, Same knee joint as in A now ow manually restored to its normal position. Both silhouettes are nmanually restored to its normal position. Both silhouettes are now ow equal. F, equal. F, ““Drop backDrop back”” or or sagging of tibiasagging of tibia in foreground in relation in foreground in relation to femur in presence of posterior cruciate disruption.to femur in presence of posterior cruciate disruption.

Figure 43Figure 43--51 With 51 With posterior posterior drawer testingdrawer testing, loss of , loss of normal stepnormal step--off of medial off of medial tibial plateau with respect tibial plateau with respect to medial femoral condyle to medial femoral condyle indicates posterior cruciate indicates posterior cruciate ligament tear.ligament tear.

Figure 43Figure 43--54 54 Quadriceps Quadriceps active testactive test for posterior for posterior cruciate ligament deficiency.cruciate ligament deficiency.

Figure 43Figure 43--62 Demonstration 62 Demonstration of shift in vertical axis away of shift in vertical axis away from center of tibia as tibia from center of tibia as tibia shifts excessively and shifts excessively and abnormally in relation to abnormally in relation to femur. Position of femur is femur. Position of femur is designated by shaded area.designated by shaded area.

Tests (Signs)Tests (Signs)Anteromedial rotary instabilityAnteromedial rotary instability–– SlocumSlocum

Anterolateral rotary instabilityAnterolateral rotary instability–– Slocum, lateral pivotSlocum, lateral pivot--shift (shift (MacIntoshMacIntosh or or

LemaireLemaire), active pivot), active pivot--shift, shift, LoseeLosee, jerk , jerk ((HughstonHughston), crossover (Arnold), Noyes ), crossover (Arnold), Noyes (flexion(flexion--rotation drawer), flexionrotation drawer), flexion--extensionextension--valgusvalgus, Nakajima (, Nakajima (““NN””), ), Martens Martens

PosteromedialPosteromedial rotary instabilityrotary instability–– HughstonHughston posteromedialposteromedial and and

posterolateral drawer signposterolateral drawer signPosterolateral rotary instabilityPosterolateral rotary instability–– HughstonHughston posteromedialposteromedial and and

posterolateral drawer sign, posterolateral drawer sign, JakobJakob(reverse pivot(reverse pivot--shift), external rotation shift), external rotation recurvatum, dynamic posterior shift, recurvatum, dynamic posterior shift, active posterolateral drawer sign, active posterolateral drawer sign, LoomerLoomer posterolateral posterolateral rotatoryrotatory instabilityinstability

Tests (Signs)Tests (Signs)

PlicaPlica–– mediopatellarmediopatellar plicaplica, , plicaplica ““stutterstutter””, ,

HughstonHughston plicaplica

PatellaPatella–– (Noble) compression & grinding (inhibition), (Noble) compression & grinding (inhibition),

((FairbankFairbank) apprehension, J sign, passive ) apprehension, J sign, passive patellar tilt, Clarke sign, Waldron, McConnell, patellar tilt, Clarke sign, Waldron, McConnell, lateral pull, lateral pull, ZohlerZohler sign, sign, FrundFrund sign, Dreyer, sign, Dreyer, Q angle (PQ angle (P--F angle), Daniel quadriceps F angle), Daniel quadriceps neutral angle, Wilsonneutral angle, Wilson

TinelTinel sign, Noble compression (ITB)sign, Noble compression (ITB)

Quadriceps (Q) angleQuadriceps (Q) angle

Figure 45Figure 45--5 Roentgenographic 5 Roentgenographic techniques for evaluation of techniques for evaluation of patellofemoral joint. A, patellofemoral joint. A, Infrapatellar Infrapatellar viewview. B, . B, Axial viewAxial view. C, . C, Skyline viewSkyline view..

Figure 45Figure 45--6 6 Lateral tilt of patellaLateral tilt of patella on axial view.on axial view.

Figure 45Figure 45--7 Measurements of patellofemoral 7 Measurements of patellofemoral congruence. congruence. MM, medial condyle; , medial condyle; LL, lateral condyle; , lateral condyle; SS, , sulcussulcus; ; PP, patellar ridge; , patellar ridge; FF, facet. Angle , facet. Angle MSLMSL is is the the sulcussulcus angleangle (average, 137x; SD, 6x). Line (average, 137x; SD, 6x). Line SOSO is is the zero reference line bisecting the the zero reference line bisecting the sulcussulcus angle. angle. Angle Angle PSOPSO is the is the congruence anglecongruence angle (average, (average, −−8x; 8x; SD, 6x). Line SD, 6x). Line PFPF (lateral facet) and line (lateral facet) and line MLML form the form the patellofemoral angle that should diverge laterally.patellofemoral angle that should diverge laterally.

Other Diagnostic StudiesOther Diagnostic StudiesRoentgenographyRoentgenographyNuclear imagingNuclear imaging–– stress fracture, early arthritis, reflex stress fracture, early arthritis, reflex

sympathetic dystrophy (RSD), osteonecrosissympathetic dystrophy (RSD), osteonecrosisMagnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)–– ligament injury, meniscal pathology, articular ligament injury, meniscal pathology, articular

cartilage injurycartilage injuryComputed tomographyComputed tomography–– bony lesion, patellar tilt, certain fracturebony lesion, patellar tilt, certain fracture

CT arthrographyCT arthrography–– articular surfaces of the Particular surfaces of the P--F joint, patient F joint, patient

cannot tolerate MRIcannot tolerate MRIThermographyThermography–– RSD (limited case)RSD (limited case)

UltrasonographyUltrasonography–– patellar patellar tendinitistendinitis, hematoma, soft tissue lesion, hematoma, soft tissue lesion

ArthroscopyArthroscopy

Figure 43Figure 43--37 37 ArthrogramArthrogram of knee showing tear of knee showing tear of meniscus.of meniscus.

Figure 48Figure 48--1 A, Suprapatellar 1 A, Suprapatellar pouch with view of pouch with view of undersurface of undersurface of articularisarticularisgenu. B, Tangential view of genu. B, Tangential view of patellofemoral articulation. C, patellofemoral articulation. C, Normal medial Normal medial parapatellarparapatellarplicaplica. D, . D, PosteromedialPosteromedialcompartment is seen by compartment is seen by passing arthroscope through passing arthroscope through intercondylar notch after intercondylar notch after viewing medial compartment. viewing medial compartment. E, E, PosteromedialPosteromedialcompartment as seen through compartment as seen through posteromedialposteromedial portal, which is portal, which is made after completion of made after completion of routine examination if routine examination if complete complete posteromedialposteromedial view view is not satisfactory. F, Medial is not satisfactory. F, Medial meniscus and medial meniscus and medial compartment. G, Cruciate compartment. G, Cruciate ligaments with fatty synovium ligaments with fatty synovium covering posterior cruciate covering posterior cruciate ligament. H, View of lateral ligament. H, View of lateral meniscus and lateral meniscus and lateral compartment. I, View of compartment. I, View of posterior horn of lateral posterior horn of lateral meniscus and meniscus and poplitealpoplitealtendon though hiatus. J, tendon though hiatus. J, Posterolateral view of knee Posterolateral view of knee with arthroscope in with arthroscope in anterolateral portal showing anterolateral portal showing poplitealpopliteal tendon insertion into tendon insertion into femur in femur in poplitealpopliteal hiatus.hiatus.

Internal DerangementInternal DerangementInternal derangementInternal derangement (1784) by William Hey, a (1784) by William Hey, a variety of variety of intraarticularintraarticular and and extraarticularextraarticulardisturbances, usually of traumatic origin, interfere disturbances, usually of traumatic origin, interfere with the function of the jointwith the function of the joint““DerangedDeranged””–– a keen sense of clinical judgmenta keen sense of clinical judgment–– roentgenogramsroentgenograms–– MRIMRI–– arthroscopyarthroscopy–– at times, surgical explorationat times, surgical exploration

Figure 43Figure 43--26 Proposed scheme to 26 Proposed scheme to explain relationship between explain relationship between mechanical alterations in knee mechanical alterations in knee joint and biological response.joint and biological response.

Internal Derangement of the Internal Derangement of the KneeKnee

EtiologyEtiology–– sports, trauma (injury), congenital sports, trauma (injury), congenital

SymptomsSymptoms–– pain, swelling, tender, effusion, pain, swelling, tender, effusion,

pain & decrease of ROMpain & decrease of ROM

Physical examinationPhysical examinationRadiographsRadiographs–– AP, lateral, MerchantAP, lateral, Merchant

MRI (if indicated)MRI (if indicated)ArthroscopyArthroscopy–– menisci (medial & lateral), menisci (medial & lateral),

ligaments (ACL, PCL, MCL, PLC), ligaments (ACL, PCL, MCL, PLC), cartilage, bone, synovium & cartilage, bone, synovium & plicaplica

Figure 48Figure 48--8 A, Calcified stump of 8 A, Calcified stump of anterior cruciate ligament after anterior cruciate ligament after chronic tear. B, Empty lateral wall chronic tear. B, Empty lateral wall sign indicating anteriorsign indicating anterior--cruciatecruciate--ligamentligament--deficient knee; anterior deficient knee; anterior cruciate ligament can be attached to cruciate ligament can be attached to posterior cruciate ligament, giving posterior cruciate ligament, giving false indication of functional ligament.false indication of functional ligament.

Figure 48-4 A, Bucket handle tear of medial meniscus that has flipped into intercondylar notch; in this position, meniscus may cause intermittent symptoms. B, Locked bucket handle tear of medial meniscus.

Ligament Injuries & InstabilityLigament Injuries & InstabilityValgusValgus (MCL)(MCL)VarusVarus (LCL)(LCL)Anterior (ACL)Anterior (ACL)Posterior (PCL)Posterior (PCL) Figure 43Figure 43--45 45 LigamentousLigamentous lesions and lesions and

associated passive instability. A, Tear associated passive instability. A, Tear confined to tibial collateral ligament; confined to tibial collateral ligament; posterior corner and posterior capsule posterior corner and posterior capsule (shaded)(shaded) are intact. are intact. ValgusValgus stress stress applied to knee will not cause medial applied to knee will not cause medial opening. This is possible only when knee opening. This is possible only when knee is flexed about 30 degrees to relax is flexed about 30 degrees to relax posterior capsule, thereby eliminating its posterior capsule, thereby eliminating its lateral stabilizing action. B, If knee lateral stabilizing action. B, If knee shows medial opening in extension, shows medial opening in extension, involvement of cruciate ligament is involvement of cruciate ligament is possibility even if no significant drawer possibility even if no significant drawer sign can be elicited. C, If sign can be elicited. C, If valgusvalgusinstability extends across to lateral side instability extends across to lateral side in both flexion and extension, both in both flexion and extension, both cruciate ligaments are torn.cruciate ligaments are torn.

Figure 48-2 A, Grade I medial capsular sprain in patient with torn anterior cruciate ligament. B, Grade II sprain of medial collateral ligament, with some mild laxity of meniscotibial ligament as evidenced by abnormal elevation of meniscus off tibial articular surface when valgus stress is applied.

Figure 43Figure 43--128 Treatment algorithm for 128 Treatment algorithm for posterior cruciate ligament avulsion posterior cruciate ligament avulsion fracturefracture..

Figure 43Figure 43--129 Screw 129 Screw reattachment of reattachment of bone bone fragment avulsed with fragment avulsed with posterior cruciate posterior cruciate ligament from posterior ligament from posterior tibiatibia..

Figure 43Figure 43--102 Repair of 102 Repair of avulsion of tibial avulsion of tibial attachment of anterior attachment of anterior cruciate ligamentcruciate ligament with with fragment of bone. Crater in fragment of bone. Crater in tibia should be deepened, tibia should be deepened, and bone fragment on end and bone fragment on end of ligament is pulled into of ligament is pulled into crater depth to restore crater depth to restore tension in avulsed ligament.tension in avulsed ligament.

Figure 14Figure 14--14 Meyers and 14 Meyers and McKeever'sMcKeever'sclassification of classification of fractures of the anterior tibial fractures of the anterior tibial spinespine. . A,A, Type I fracture with no displacement Type I fracture with no displacement of the fracture. of the fracture. B,B, Type II fracture with Type II fracture with elevation of the anterior portion of the anterior elevation of the anterior portion of the anterior tibial spine, but with the fracture posteriorly tibial spine, but with the fracture posteriorly reduced. reduced. C,C, Type III fracture that is totally Type III fracture that is totally displaced.displaced.

Figure 43Figure 43--132 Treatment algorithm for 132 Treatment algorithm for chronic posterior cruciate ligament injurieschronic posterior cruciate ligament injuries..

Classifications of Tears of the MenisciClassifications of Tears of the Menisci< based on location or type of tear, etiology, and other factors< based on location or type of tear, etiology, and other factors >>

< most of the commonly used classifications are based on the < most of the commonly used classifications are based on the type of tear found at surgery >type of tear found at surgery >Longitudinal tearsLongitudinal tearsTransverse and oblique tearsTransverse and oblique tearsA combination of longitudinal and transverse tearsA combination of longitudinal and transverse tearsTears associated with cystic menisciTears associated with cystic menisciTears associated with discoid menisciTears associated with discoid menisci

Figure 48Figure 48--9 Four basic 9 Four basic patterns of meniscal tears: patterns of meniscal tears: II, , longitudinallongitudinal; ; IIII,, horizontalhorizontal; ; IIIIII, , obliqueoblique; and ; and IVIV, , radialradial..

Figure 48Figure 48--10 10 Bucket handle Bucket handle teartear, displaced , displaced centrally.centrally.

Figure 48Figure 48--11 11 Peripheral tearsPeripheral tears. . AA, , MeniscocapsularMeniscocapsulartear. tear. BB, Peripheral , Peripheral longitudinal tear.longitudinal tear.

Figure 48Figure 48--12 12 AA, , Posterior oblique Posterior oblique tear. tear. BB, anterior , anterior oblique tear.oblique tear.

OO’’Connor Connor Classification of Meniscal TearsClassification of Meniscal Tears

Longitudinal tearsLongitudinal tearsHorizontal tearsHorizontal tearsOblique tearsOblique tearsRadial tearsRadial tearsVariations, includeVariations, include–– flap tearsflap tears–– complex tearscomplex tears–– degenerative tears degenerative tears

Types Of Meniscal Excisions (OTypes Of Meniscal Excisions (O’’Connor)Connor)

Partial meniscectomyPartial meniscectomySubtotal meniscectomySubtotal meniscectomyTotal meniscectomyTotal meniscectomy

Figure 48Figure 48--14 Types of meniscal excision. 14 Types of meniscal excision. AA, , Partial meniscectomyPartial meniscectomy. . BB, , Subtotal meniscectomySubtotal meniscectomy. . CC, , Total meniscectomyTotal meniscectomy..

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

Figure 43Figure 43--38 Zones of 38 Zones of potential meniscal healing.potential meniscal healing.

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

Figure 43Figure 43--40 40 Meniscal allograftMeniscal allograft..

Figure 43Figure 43--41 Cyst of lateral meniscus.41 Cyst of lateral meniscus.

Patellofemoral DisordersPatellofemoral DisordersLateral patellar compression syndromeLateral patellar compression syndromePatellar subluxation & dislocationPatellar subluxation & dislocation–– acute dislocation of the patellaacute dislocation of the patella–– chronic subluxation of the patellachronic subluxation of the patella–– recurrent dislocation of the patellarecurrent dislocation of the patella–– chronic dislocation of the patellachronic dislocation of the patella

Chondromalacia of patellaChondromalacia of patellaPatellofemoral arthritisPatellofemoral arthritis

Figure 48Figure 48--9 Patellofemoral articulation viewed from anterolateral portal. 9 Patellofemoral articulation viewed from anterolateral portal. A, Lateral tracking A, Lateral tracking of patella is evident, as is of patella is evident, as is grade IIgrade II chondromalacia of lateral facet. B, chondromalacia of lateral facet. B, Grade IVGrade IVchondromalacia of chondromalacia of trochleatrochlea with bare bone exposed.with bare bone exposed.

Figure 14Figure 14--8 Diagrammatic 8 Diagrammatic representation of an representation of an osteochondral fracture of theosteochondral fracture of thelateral femoral condylelateral femoral condyle (B)(B) and the and the medial pole of the patellamedial pole of the patella (A),(A), both both secondary to patellar dislocation. secondary to patellar dislocation. Radiographs may appear normal, Radiographs may appear normal, but the but the hemarthrosishemarthrosis aspirate will aspirate will contain fat droplets. Arthroscopy contain fat droplets. Arthroscopy is indicated when these chondral is indicated when these chondral or osteochondral fractures are or osteochondral fractures are suspected.suspected.

Etiological Factors in Chondromalacia of PatellaEtiological Factors in Chondromalacia of PatellaBiomechanical causes Biomechanical causes

–– acute acute dislocation of the patella with a chondral or osteochondral fracdislocation of the patella with a chondral or osteochondral fracture ture direct trauma (e.g., a fall on or a blow to the patella) direct trauma (e.g., a fall on or a blow to the patella) fracture of the patella, resulting in incongruous surfaces fracture of the patella, resulting in incongruous surfaces

–– chronic chronic recurrent subluxation or dislocation of the patella (secondary trecurrent subluxation or dislocation of the patella (secondary to femoral o femoral dysplasiadysplasia, small patella, patella , small patella, patella altaalta, femoral , femoral anteversionanteversion, external tibial , external tibial torsion, or even anterior cruciate ligament insufficiency) torsion, or even anterior cruciate ligament insufficiency) increased quadriceps angle increased quadriceps angle quadriceps muscle imbalance, either weakness or abnormal attachmquadriceps muscle imbalance, either weakness or abnormal attachment of ent of the the vastusvastus medialismedialispatella patella altaaltaposttraumatic posttraumatic malalignmentmalalignment following femoral shaft fracture following femoral shaft fracture excessive lateral pressure syndrome excessive lateral pressure syndrome meniscal injury with alteration of synchronous pattern of patellmeniscal injury with alteration of synchronous pattern of patellar ar movement and loss of stability movement and loss of stability reflex sympathetic dystrophy reflex sympathetic dystrophy medial femoral condylar ridge medial femoral condylar ridge

Biochemical causes Biochemical causes –– disease disease

rheumatoid arthritis rheumatoid arthritis recurrent recurrent hemarthrosishemarthrosisalkaptonuriaalkaptonuriaperipheral synovitis peripheral synovitis sepsis and adhesions sepsis and adhesions

–– iatrogenic iatrogenic repeated intraarticular steroid injections repeated intraarticular steroid injections prolonged immobilization prolonged immobilization

–– degenerativedegenerative——primary osteoarthritis primary osteoarthritis

Classification of Patellofemoral DisordersClassification of Patellofemoral DisordersTrauma (conditions caused by trauma in otherwise normal knee) Trauma (conditions caused by trauma in otherwise normal knee)

–– acute trauma acute trauma contusion contusion fracture fracture

–– patella patella –– femoral femoral trochleatrochlea–– proximal tibial epiphysis (tubercle) proximal tibial epiphysis (tubercle)

dislocation (rare in normal knee) dislocation (rare in normal knee) rupture rupture

–– quadriceps tendon quadriceps tendon –– patellar tendon patellar tendon

–– repetitive trauma (overuse syndromes) repetitive trauma (overuse syndromes) patellar patellar tendinitistendinitis ((““jumper's kneejumper's knee””) ) quadriceps quadriceps tendinitistendinitisperipatellarperipatellar tendinitistendinitis (e.g., anterior knee pain in adolescent caused by hamstring con(e.g., anterior knee pain in adolescent caused by hamstring contracture) tracture) prepatellarprepatellar bursitis (bursitis (““housemaid's kneehousemaid's knee””) ) apophysitisapophysitis

–– OsgoodOsgood--SchlatterSchlatter disease disease –– SindingSinding--LarsenLarsen--Johansson disease Johansson disease

–– late effects of trauma late effects of trauma posttraumatic chondromalacia patellae posttraumatic chondromalacia patellae posttraumatic patellofemoral arthritis posttraumatic patellofemoral arthritis anterior fat pad syndrome (posttraumatic fibrosis) anterior fat pad syndrome (posttraumatic fibrosis) reflex sympathetic dystrophy of patella reflex sympathetic dystrophy of patella patellar osseous dystrophy patellar osseous dystrophy acquired patella acquired patella inferainferaacquired quadriceps fibrosis acquired quadriceps fibrosis

Patellofemoral Patellofemoral dysplasiadysplasia–– lateral patellar compression syndrome lateral patellar compression syndrome

secondary chondromalacia patellae secondary chondromalacia patellae secondary patellofemoral arthritis secondary patellofemoral arthritis

–– chronic subluxation of patella chronic subluxation of patella secondary chondromalacia patellae secondary chondromalacia patellae secondary patellofemoral arthritis secondary patellofemoral arthritis

–– recurrent dislocation of patella recurrent dislocation of patella associated fractures associated fractures

–– osteochondral (intraarticular) osteochondral (intraarticular) –– avulsion (avulsion (extraarticularextraarticular) )

secondary chondromalacia patellae secondary chondromalacia patellae secondary patellofemoral arthritis secondary patellofemoral arthritis

–– chronic dislocation of patella chronic dislocation of patella congenital congenital acquired acquired

Idiopathic chondromalacia patellae Idiopathic chondromalacia patellae OsteochondritisOsteochondritis dissecansdissecans

–– patella patella –– femoral femoral trochleatrochlea

Synovial Synovial plicaeplicae (anatomical variant made symptomatic by acute or repetitive tra(anatomical variant made symptomatic by acute or repetitive trauma) uma) –– medial patellar (medial patellar (““shelfshelf””) ) –– suprapatellar suprapatellar –– lateral patellar lateral patellar

Figure 48Figure 48--10 Patellofemoral joint 10 Patellofemoral joint viewed from superolateral portal; viewed from superolateral portal; lateral subluxation of patellalateral subluxation of patella is evident.is evident.

Figure 48Figure 48--11 11 Grade IIIGrade IIIchondromalacia of patella involving chondromalacia of patella involving central ridge and lateral facet.central ridge and lateral facet.

Surgical Guidelines for Patients Who Have Not Responded to VigorSurgical Guidelines for Patients Who Have Not Responded to Vigorous, ous, Appropriate Conservative Treatment for Patellofemoral PainAppropriate Conservative Treatment for Patellofemoral Pain

LATERAL RELEASE LATERAL RELEASE Consistent tenderness and tightness in lateral retinaculum (Consistent tenderness and tightness in lateral retinaculum (extraarticularextraarticular lidocainelidocaineinjection can be tried first in tender area) usually associated injection can be tried first in tender area) usually associated with patellar tilt or with patellar tilt or subluxation. subluxation. Painful Painful arthrosisarthrosis in patellofemoral joint with in patellofemoral joint with roentgenographicallyroentgenographically documented lateral documented lateral patellar tilt and minimal or no subluxation. patellar tilt and minimal or no subluxation. In association with realignment of patella for chronic lateral sIn association with realignment of patella for chronic lateral subluxation or dislocation ubluxation or dislocation but not as isolated procedure for realignment (unless future CT but not as isolated procedure for realignment (unless future CT studies show significant studies show significant relief of subluxation after lateral release). relief of subluxation after lateral release). Persistent patellofemoral pain and lateral traction osteophyte aPersistent patellofemoral pain and lateral traction osteophyte at lateral retinacular t lateral retinacular insertion into patella. insertion into patella.

PROXIMAL (SOFT TISSUE) REALIGNMENT PROXIMAL (SOFT TISSUE) REALIGNMENT Skeletally immature with history of recurrent patellar dislocatiSkeletally immature with history of recurrent patellar dislocation. on. Skeletally immature or mature with persistent patellofemoral paiSkeletally immature or mature with persistent patellofemoral pain and elevated n and elevated congruence angle with or without significant patellar tilt and ucongruence angle with or without significant patellar tilt and unresponsive to vigorous, nresponsive to vigorous, appropriate rehabilitation program. Minimal or nonexistent appropriate rehabilitation program. Minimal or nonexistent arthrosisarthrosis. . DysplasticDysplastic femoral femoral trochleatrochlea and evidence of poor medial patellar support by and evidence of poor medial patellar support by vastusvastusmedialismedialis obliquusobliquus, causing recurrent patellar subluxation or dislocation. , causing recurrent patellar subluxation or dislocation. Realignment of patella without diminishing overall patellar contRealignment of patella without diminishing overall patellar contact stress (act stress (arthrosisarthrosisminimal or nonexistent). minimal or nonexistent).

ANTEROMEDIAL TIBIAL TUBERCLE TRANSFER (Closed ANTEROMEDIAL TIBIAL TUBERCLE TRANSFER (Closed physisphysis is prerequisite)is prerequisite)Persistent patellofemoral pain related to Persistent patellofemoral pain related to malalignmentmalalignment with excessive patellar tilt or with excessive patellar tilt or elevated congruence angle and need for relief of patellar contacelevated congruence angle and need for relief of patellar contact stress because of t stress because of patellar patellar arthrosisarthrosis. . VastusVastus medialismedialis obliquusobliquus advancement may be added as necessary to advancement may be added as necessary to balance patella in balance patella in trochleatrochlea. . Lateral facet Lateral facet arthrosisarthrosis and elevated quadriceps (Q) angle >22 degrees with patella and elevated quadriceps (Q) angle >22 degrees with patella centered in centered in trochleatrochlea. . Failed lateral release without evidence of lateral retinacular rFailed lateral release without evidence of lateral retinacular reattachment and with eattachment and with significant residual lateral tilt.significant residual lateral tilt.

Repair of Patellofemoral Instability Repair of Patellofemoral Instability

Proximal realignment Proximal realignment Recurrence in immature patient Recurrence in immature patient

Oblique Fulkerson type Oblique Fulkerson type osteotomyosteotomy leaving leaving at least two thirds of at least two thirds of postmedialpostmedial cortex cortex intact intact

Recurrence with grade 3 or grade 4 Recurrence with grade 3 or grade 4 chondromalacia chondromalacia

Lateral release with Lateral release with distalizationdistalization and and medializationmedialization of tibial of tibial tuberositytuberosity(Simmons procedure) (Simmons procedure)

Recurrence with Recurrence with InsallInsall index >1.2 index >1.2

Modified Modified ElmslieElmslie--TrillatTrillat lateral release and lateral release and medial medial tuberositytuberosity transfer; arthroscopic transfer; arthroscopic evaluation and medial evaluation and medial tuberositytuberosity transfer transfer can be done if there is no evidence of can be done if there is no evidence of lateral tightness lateral tightness

Recurrence with Recurrence with InsallInsall index <1.2 and Q index <1.2 and Q angle near 20 degrees angle near 20 degrees

Arthroscope and repair of medial Arthroscope and repair of medial patellofemoral ligament and medial patellofemoral ligament and medial retinaculum retinaculum

Acute dislocation with associated Acute dislocation with associated osteochondral fragment or highosteochondral fragment or high--level level athlete at end of season athlete at end of season

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

Procedure Procedure Determining Factors Determining Factors

Operative Treatment of Recurrent Subluxation or Dislocation of POperative Treatment of Recurrent Subluxation or Dislocation of Patellaatella

West and SotoWest and Soto--Hall Hall Skeletally mature, salvage procedure Skeletally mature, salvage procedure PatellectomyPatellectomy with extensor with extensor realignment realignment

HughstonHughston, modified , modified ElmslieElmslie--TrillatTrillat

Recurrent dislocations, skeletally mature, Q angle Recurrent dislocations, skeletally mature, Q angle approaching 20 degrees approaching 20 degrees

Proximal and distal Proximal and distal realignment realignment

Q angle >20 degrees, skeletally mature Q angle >20 degrees, skeletally mature

ElmslieElmslie--TrillatTrillatQ angle >20 degrees, skeletally immature (soft Q angle >20 degrees, skeletally immature (soft tissue realignment) tissue realignment)

RouxRoux--GoldthwaitGoldthwait, , GaleazziGaleazzi

Recurrent subluxation or dislocation Recurrent subluxation or dislocation Distal extensor realignment Distal extensor realignment

InsallInsall, Madigan et al. , Madigan et al. Subluxation or dislocation, Q angle <20 degrees Subluxation or dislocation, Q angle <20 degrees Proximal extensor Proximal extensor realignment realignment

Highly competitive athlete near end of season Highly competitive athlete near end of season

OpenOpenAcute or Acute or subacutesubacute dislocation in association with dislocation in association with osteochondral fracture osteochondral fracture

Repair of medial Repair of medial patellofemoral ligament and patellofemoral ligament and VM VM

Lateral tilt with minimal lateral subluxation on Lateral tilt with minimal lateral subluxation on roentgenogram in combination with realignment roentgenogram in combination with realignment procedure procedure

ArthroscopicArthroscopicTight lateral structures Tight lateral structures

OpenOpenRecurrent subluxation, relatively normal Q angle Recurrent subluxation, relatively normal Q angle Lateral retinacular release Lateral retinacular release

TechniquesTechniquesIndicationsIndicationsOperative Procedure Operative Procedure

Figure 45Figure 45--8 8 InsallInsall technique of technique of proximal realignment of proximal realignment of patellapatella. A, Medial and lateral . A, Medial and lateral vastivasti are separated from are separated from rectus rectus femorisfemoris tendon. B, tendon. B, Lateral release is performed; Lateral release is performed; synovium is left intact. C, synovium is left intact. C, Completed closure is tight to Completed closure is tight to hold patella securely in hold patella securely in femoral groove. D, Remaining femoral groove. D, Remaining medial flap is sutured without medial flap is sutured without further overlap.further overlap.

Figure 45Figure 45--9 9 Technique of MadiganTechnique of Madigan et al. for et al. for proximal realignment of patella. A, Incision. B, proximal realignment of patella. A, Incision. B, Division of tendon of Division of tendon of vastusvastus medialismedialisobliquusobliquus muscle. C, Synovial relaxing muscle. C, Synovial relaxing incision. D, Suture of transferred insertion of incision. D, Suture of transferred insertion of vastusvastus medialismedialis to patella and quadriceps to patella and quadriceps tendon.tendon. Figure 45Figure 45--10 10 RouxRoux--

GoldthwaitGoldthwait operationoperationfor recurrent for recurrent dislocation of patella. dislocation of patella. Patellar tendon is Patellar tendon is split; lateral half is split; lateral half is transplanted transplanted medially. A medially. A preferable procedure preferable procedure would be to transfer would be to transfer medial half of tendon medial half of tendon medially.medially.

Figure 45Figure 45--11 11 ElmslieElmslie--TrillatTrillat procedureprocedure as as modified by Cox. A, Lateral modified by Cox. A, Lateral parapatellarparapatellarincision. B, Superficial and deep incision. B, Superficial and deep incisions of transverse fibers of lateral incisions of transverse fibers of lateral retinaculum. C, Raised bone attached to retinaculum. C, Raised bone attached to tibia by distal periosteal pedicle.tibia by distal periosteal pedicle.

Figure 45Figure 45--12 A, 12 A, ElmslieElmslie--TrillatTrillat procedureprocedure as modified by Cox. as modified by Cox. B, Cross section of tibia at level of tibial B, Cross section of tibia at level of tibial tuberositytuberosity to show to show bone cuts made to free bone cuts made to free tuberositytuberosity in center and to create in center and to create new bed for transposed new bed for transposed tuberositytuberosity to right. C, Cross section to right. C, Cross section of of tuberositytuberosity fixed with screw in new location fixed with screw in new location anteromediallyanteromedially. Screw should not penetrate posterior cortex.. Screw should not penetrate posterior cortex.

Figure 43Figure 43--153 153 MaquetMaquettechniquetechnique of of advancement of tibial advancement of tibial tuberositytuberosity by elevation of by elevation of tibial crest. A, Drill holes tibial crest. A, Drill holes and line of and line of osteotomyosteotomy. B, . B, OsteotomyOsteotomy is sprung is sprung open and propped with open and propped with iliac graft.iliac graft.

Bipartite PatellaBipartite Patella

Figure 43Figure 43--150 150 Ogata techniqueOgata technique for bipartite patella. A, Oblique skin incision is made over for bipartite patella. A, Oblique skin incision is made over distal portion of distal portion of vastusvastus lateralislateralis tendon, extending just distal to tendon, extending just distal to midportionmidportion of separated area of separated area of patella. B, of patella. B, VastusVastus lateralislateralis tendon is split along its middle fibers and insertion to painfutendon is split along its middle fibers and insertion to painful l patellar fragment is detached patellar fragment is detached subperiosteallysubperiosteally. Continuity of tendon. Continuity of tendon--periosteum complex to periosteum complex to main portion of patella is preserved. C, Fragment is relieved frmain portion of patella is preserved. C, Fragment is relieved from muscle traction without om muscle traction without causing a causing a mediolateralmediolateral imbalance that would affect patellofemoral tracking. Care shoulimbalance that would affect patellofemoral tracking. Care should be d be taken not to injure synovial capsule to preserve some blood supptaken not to injure synovial capsule to preserve some blood supply to fragment.ly to fragment.

EpiphysitisEpiphysitis of Tibial of Tibial TuberosityTuberosity(Osgood(Osgood--SchlatterSchlatter Disease)Disease)Surgery rarely, simple conservative measuresSurgery rarely, simple conservative measures

–– restriction of activities or cast immobilization restriction of activities or cast immobilization for 3 to 6 weeksfor 3 to 6 weeks

Patella Patella altaaltaSurgery, symptoms are persistent and Surgery, symptoms are persistent and severely disablingseverely disabling

–– tibial tibial sequestrectomysequestrectomy (removal of the (removal of the fragments)fragments)

–– inserting bone pegs into the tibial inserting bone pegs into the tibial tuberositytuberosity–– excision of the bony prominence through a excision of the bony prominence through a

longitudinal incision in the patellar tendonlongitudinal incision in the patellar tendonComplicationsComplications

–– subluxations of the patella, patella subluxations of the patella, patella altaalta, , nonunion of the bony fragment to the tibia, and nonunion of the bony fragment to the tibia, and premature fusion of the anterior part of the premature fusion of the anterior part of the epiphysis with resulting genu recurvatumepiphysis with resulting genu recurvatum

Figure 29Figure 29--10 Bosworth technique 10 Bosworth technique for insertion of bone pegs for for insertion of bone pegs for OsgoodOsgood--SchlatterSchlatter disease.disease.

Figure 29Figure 29--11 11 FerciotFerciot and Thomson excision of and Thomson excision of ununitedununited tibial tibial tuberositytuberosity. A, . A, Tibial Tibial tuberositytuberosity has been has been exposed.Bexposed.B, Bony prominence has been excised., Bony prominence has been excised.

OsteochondritisOsteochondritis DissecansDissecans of the Kneeof the Kneein children with open in children with open physesphysesusually heals when treated with usually heals when treated with cast immobilizationcast immobilizationpreferable to excising the preferable to excising the fragment early in life and fragment early in life and creating a cratercreating a crater

Figure 29Figure 29--12 A, 12 A, OsteochondritisOsteochondritisdissecansdissecans of medial femoral of medial femoral condylecondyle in child with open in child with open physisphysis. B, Four years later, . B, Four years later, physisphysis is closed and lesion has is closed and lesion has healed.healed.

Figure 29Figure 29--13 A, 13 A, OsteochondritisOsteochondritis dissecansdissecans of medial femoral of medial femoral condylecondyle treated with knee immobilizer in 13treated with knee immobilizer in 13--yearyear--old child old child with with physisphysis still open. B, At 3still open. B, At 3--month followmonth follow--up defect up defect appears to be healing; possible osteochondral loose body appears to be healing; possible osteochondral loose body noted. C, At 5noted. C, At 5--month followmonth follow--up patient is asymptomatic with up patient is asymptomatic with healed lesion on roentgenogram and a loose body that is healed lesion on roentgenogram and a loose body that is asymptomatic.asymptomatic.

Figure 43Figure 43--146 146 OsteochondritisOsteochondritis dissecansdissecans of of knee, knee, nonoperativenonoperative treatmenttreatment. A, Lesion in . A, Lesion in adolescent treated adolescent treated nonoperativelynonoperatively in cast for in cast for 9 months. B, Several years later, complete 9 months. B, Several years later, complete healing is apparent, and knee is healing is apparent, and knee is asymptomatic.asymptomatic.

Figure 43Figure 43--147 147 OsteochondritisOsteochondritis dissecansdissecans. A, . A, OsteochondritisOsteochondritis dissecansdissecans involving weightinvolving weight--bearing portion of lateral femoral condyle in bearing portion of lateral femoral condyle in 1515--yearyear--old boy. B and C, old boy. B and C, Fragment Fragment internally fixed with multiple internally fixed with multiple KirschnerKirschner wireswires..

Figure 43Figure 43--145 Sites of lesions of 145 Sites of lesions of osteochondritisosteochondritisdissecansdissecans of kneeof knee..

Figure 29Figure 29--14 A and B, Large 14 A and B, Large osteochondritisosteochondritis dissecansdissecans defect on lateral femoral condyle defect on lateral femoral condyle seen on roentgenogram and magnetic resonance imaging. seen on roentgenogram and magnetic resonance imaging. ChondroblastomaChondroblastoma was ruled out was ruled out in this patient with in this patient with physesphyses still open. C and D, still open. C and D, After 9 months of unsuccessful conservative After 9 months of unsuccessful conservative treatmenttreatment, , arthroscopy and Herbert screw fixationarthroscopy and Herbert screw fixation were performed. At the time of were performed. At the time of arthroscopy lesion was hinged but attached. Procedure requires uarthroscopy lesion was hinged but attached. Procedure requires use of image intensifier for se of image intensifier for correct guide pin placement and to correct guide pin placement and to avoid avoid physisphysis with Herbert screws. E and F, Postoperative with Herbert screws. E and F, Postoperative anteroposterior and lateral roentgenograms with Herbert screws ianteroposterior and lateral roentgenograms with Herbert screws in acceptable position.n acceptable position.

Figure 43Figure 43--148 Algorithm of Clanton and 148 Algorithm of Clanton and DeLeeDeLee for for treatment of treatment of osteochondritisosteochondritisdissecansdissecans in symptomatic adultin symptomatic adult..

OsteochondritisOsteochondritis DissecansDissecans of the Patellaof the PatellaA rare entity affects the subchondral bone and articular surfaceA rare entity affects the subchondral bone and articular surface and and the cartilage overlying the surface of the patellathe cartilage overlying the surface of the patellaAn elliptical fragment within a crater, rarely occur bilaterallyAn elliptical fragment within a crater, rarely occur bilaterallyFrequently painful and quite debilitatingFrequently painful and quite debilitatingBoys between the ages of 10 and 15 are most commonly affectedBoys between the ages of 10 and 15 are most commonly affectedSurgical treatment will not be carried out on an asymptomatic deSurgical treatment will not be carried out on an asymptomatic defectfectMRIMRIBone scan can help differentiate between the simple, asymptomatiBone scan can help differentiate between the simple, asymptomatic, c, subchondral defect in the superolateral portion of the patella asubchondral defect in the superolateral portion of the patella and nd OCD of the patellaOCD of the patella

–– in OCD of the patella is exceptionally in OCD of the patella is exceptionally ““hothot”” in comparison to dorsal in comparison to dorsal defects is defects is ““coldcold””

TreatmentTreatment–– physesphyses are still open, are still open, nonoperativenonoperative if at all possibleif at all possible

restriction of activities and immobilization for a period of timrestriction of activities and immobilization for a period of time to avoid surgical e to avoid surgical excisionexcision

–– if conservative treatment failsif conservative treatment failsthe lesion can be drilledthe lesion can be drilledthe lesion can be internally fixed with a small diameter Herbertthe lesion can be internally fixed with a small diameter Herbert screw or pinsscrew or pinsthe loose body should be removed and the crater debrided and drithe loose body should be removed and the crater debrided and drilledlledif the loose body appears to have viable subchondral bone, the cif the loose body appears to have viable subchondral bone, the crater should be rater should be freshened and the loose body placed within the crater and internfreshened and the loose body placed within the crater and internally fixedally fixed

Figure 29Figure 29--16 16 OsteochondritisOsteochondritis dissecansdissecans of of patella. A, Lateral roentgenogram. B, patella. A, Lateral roentgenogram. B, Bone Bone scanscan. C and D, . C and D, MRIMRI revealing revealing osteocartilaginousosteocartilaginous fragment including fragment including articular cartilage within crater.articular cartilage within crater.

Figure 29Figure 29--17 A and B, Roentgenograms of 17 A and B, Roentgenograms of dorsal defect of patelladorsal defect of patella in superolateral in superolateral quadrant. C and D, Magnetic resonance imaging quadrant. C and D, Magnetic resonance imaging revealing dorsal defect of patella with cystic revealing dorsal defect of patella with cystic defect noted but defect noted but not involving the articular not involving the articular cartilagecartilage..

Snapping Syndromes of the KneeSnapping Syndromes of the KneeRare, more commonly in the hip, shoulder, or elbowRare, more commonly in the hip, shoulder, or elbowTrue True ““snappingsnapping”” –– extraarticularextraarticular

–– abnormal anterior insertion of the biceps abnormal anterior insertion of the biceps femorisfemoris tendon on the fibular tendon on the fibular headhead

–– snapping snapping popliteuspopliteus tendon syndrome tendon syndrome -- between the lateral between the lateral epicondyleepicondyleand the lateral joint lineand the lateral joint line

–– abnormal insertion of the abnormal insertion of the semitendinosussemitendinosus tendontendon–– a hamstring tendon sliding over an a hamstring tendon sliding over an osteochondromaosteochondroma of the femurof the femur

Intraarticular Intraarticular ““catchingcatching”” or or ““lockinglocking””–– meniscal tears, loose bodies, patellofemoral disorders, or arthrmeniscal tears, loose bodies, patellofemoral disorders, or arthritic joint itic joint

changeschanges

JumperJumper’’s Knee (s Knee (TendinitisTendinitis of the Extensor Mechanism )of the Extensor Mechanism )

TendoosseousTendoosseous junction at the inferior pole of the junction at the inferior pole of the patellapatellaRepetitive traction or overload injury during sportsRepetitive traction or overload injury during sports

–– prolonged, repetitive microtrauma causes focal mucoid prolonged, repetitive microtrauma causes focal mucoid degeneration, fraying, and degeneration, fraying, and microtearingmicrotearing of the collagen of the collagen fibrilsfibrils

–– occasionally, a single episode of eccentric overload or a occasionally, a single episode of eccentric overload or a direct blow to the tendondirect blow to the tendon

Tenderness at the inferior pole of the patellaTenderness at the inferior pole of the patella–– associated abnormalities of patellar tracking, associated abnormalities of patellar tracking,

chondromalacia, Osgoodchondromalacia, Osgood--SchlatterSchlatter disease, or disease, or mechanical mechanical malalignmentmalalignment of the legof the leg

–– radiolucencyradiolucency and elongation of the involved pole early and elongation of the involved pole early in the processin the process

–– periosteal reaction of the anterior patellar surface periosteal reaction of the anterior patellar surface ((““tooth signtooth sign””) and tendon calcification) and tendon calcification

–– stress fracture or disruption of the extensor stress fracture or disruption of the extensor mechanismmechanism

Conservative treatmentConservative treatmentSurgical treatmentSurgical treatment

Figure 46Figure 46--33 33 Elongation Elongation of lower pole of patellaof lower pole of patella in in tennis player with long tennis player with long history of patellar history of patellar tendinitistendinitis..

Four Stages of JumperFour Stages of Jumper’’s Knees Knee<<based on symptoms (based on symptoms (BlazinaBlazina et al.)et al.)>>Phase 1Phase 1pain only after activitypain only after activityPhase 2Phase 2pain during and after activity pain during and after activity but no significant functional but no significant functional impairmentimpairmentPhase 3Phase 3pain during and after activities pain during and after activities with progressive difficulty in with progressive difficulty in satisfactory performancesatisfactory performancePhase 4Phase 4endend--stage disease with stress stage disease with stress fracture through the patella or fracture through the patella or disruption of the extensor disruption of the extensor mechanismmechanism

Figure 46Figure 46--34 34 Stress fracture Stress fracture of inferior pole of patellaof inferior pole of patella in in collegiate basketball player. collegiate basketball player. Fracture is secured with Fracture is secured with parallel screws; parallel screws; corticocancellouscorticocancellous slot graft is slot graft is placed distally across fracture.placed distally across fracture.

Synovial LesionsSynovial LesionsPigmented villonodular Pigmented villonodular synovitis (PVNS)synovitis (PVNS)Synovial Synovial ((osteo)chondromatosisosteo)chondromatosis

FIGURE 2. Loose bodies accumulate in the (A) FIGURE 2. Loose bodies accumulate in the (A) medial compartment and (B) lateral gutter. No medial compartment and (B) lateral gutter. No loose bodies remain in the (C) medial and (D) loose bodies remain in the (C) medial and (D) lateral compartments lateral compartments

FIGURE 3. (A) There were hundreds of FIGURE 3. (A) There were hundreds of brilliant white, brilliant white, cartilagelikecartilagelike loose bodies loose bodies and a few bodies adhering to the and a few bodies adhering to the hypertrophic synovium, which was excised hypertrophic synovium, which was excised (arrows). (B) Histological examination(arrows). (B) Histological examinationshows cartilaginous synovial shows cartilaginous synovial metaplasiametaplasiawith synovial hypertrophy (arrows). The with synovial hypertrophy (arrows). The disorganized chondrocytes were disorganized chondrocytes were surrounded by a thin fibrin layer (H&E, surrounded by a thin fibrin layer (H&E, original magnification 100).original magnification 100).

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

Figure 113Figure 113--18 18 Synovial Synovial osteochondromatosisosteochondromatosis of of the kneethe knee with narrowing of the joint space and with narrowing of the joint space and multiple large, calcified bodies filling the joint multiple large, calcified bodies filling the joint space and suprapatellar pouch.space and suprapatellar pouch.

Normal vs OA JointNormal vs OA JointNormal vs OA Joint

Normal kneeNormal knee Osteoarthritic kneeOsteoarthritic knee

CapsuleCapsule

CartilageCartilage

SynoviumSynovium

BoneBone

Thickened capsuleThickened capsuleCyst formationCyst formation

Sclerosis in subchondral boneSclerosis in subchondral bone

Fibrillated cartilageFibrillated cartilage

Osteophyte formationOsteophyte formation

Synovial hypertrophySynovial hypertrophy

Osteoarthritis (OA)Osteoarthritis (OA)

Primary osteoarthritisPrimary osteoarthritis–– polyarticularpolyarticular degenerative arthritis of unknown origindegenerative arthritis of unknown origin–– rarely occurs before the age of 35 yearsrarely occurs before the age of 35 years–– especially in weightespecially in weight--bearing joints, more common in bearing joints, more common in

obese patients over the age of 50 yearsobese patients over the age of 50 yearsSecondary osteoarthritisSecondary osteoarthritis

–– monarticularmonarticular–– mechanical derangement, mechanical derangement, pyogenicpyogenic infection, congenital infection, congenital

anomaly, anomaly, physealphyseal separation, separation, ligamentousligamentous instability, instability, and fracture into a joint are among the common causesand fracture into a joint are among the common causes

The prognosis is better for the primary type, The prognosis is better for the primary type, polyarticularpolyarticular degenerative arthritis, than for the degenerative arthritis, than for the secondary typesecondary typeThe progression of primary osteoarthritis is usually The progression of primary osteoarthritis is usually slower and less relentlessslower and less relentlessAn association of osteoarthritis of the hip with An association of osteoarthritis of the hip with occupations requiring heavy lifting and elite sporting occupations requiring heavy lifting and elite sporting activity, no such relationship between osteoarthritis activity, no such relationship between osteoarthritis of the knee and activity levelsof the knee and activity levels

Figure 25Figure 25--8 In 8 In osteoarthritis of osteoarthritis of kneeknee varusvarus or or valgusvalgusdeformities deformities concentrate concentrate stress of weightstress of weight--bearing in either bearing in either medial or lateral medial or lateral part of joint, and part of joint, and degenerative degenerative changes in that changes in that part are part are accelerated.accelerated.

OA of the OA of the KneeKneeResult of mechanical and Result of mechanical and biological events that destabilize biological events that destabilize the normal processes of the normal processes of degradation and synthesis of degradation and synthesis of articular cartilage chondrocytes, articular cartilage chondrocytes, extracellular matrix, and extracellular matrix, and subchondral bonesubchondral boneInclude increased water content, Include increased water content, decreased proteoglycan content, decreased proteoglycan content, and altered collagen matrix, all and altered collagen matrix, all leading to the deterioration of leading to the deterioration of articular cartilagearticular cartilageRadiographsRadiographs

–– nonuniformnonuniform joint space narrowingjoint space narrowing–– cortical sclerosis on the weightcortical sclerosis on the weight--

bearing bony surfacesbearing bony surfaces–– subchondral cystsubchondral cyst–– marginal marginal osteophytesosteophytes–– loose bodies and subluxationloose bodies and subluxation

TreatmentTreatment–– conservativeconservative–– surgicalsurgical

Treatments of the OA KneeTreatments of the OA Knee

DebridementDebridementOsteochondral and Osteochondral and autologousautologouschondrocyte transplantationchondrocyte transplantationProximal (high) tibial Proximal (high) tibial osteotomyosteotomy–– close or open wedge, medial or lateralclose or open wedge, medial or lateral–– dome dome

Distal femoral Distal femoral osteotomyosteotomyArthroplastyArthroplasty–– unicompartmentalunicompartmental knee arthroplastyknee arthroplasty–– total knee arthroplastytotal knee arthroplasty

ArthrodesisArthrodesis

Distal Femoral Distal Femoral OsteotomyOsteotomy

Figure 25Figure 25--23 Coventry technique of 23 Coventry technique of lower femoral lower femoral osteotomyosteotomy. Angle to . Angle to be corrected is measured on be corrected is measured on preoperative roentgenogram, and preoperative roentgenogram, and nail of blade plate is driven into nail of blade plate is driven into femoral femoral metaphysismetaphysis so that plate so that plate will accomplish desired correction will accomplish desired correction when attached to when attached to osteotomizedosteotomizedfemoral shaft. Wedge with apical femoral shaft. Wedge with apical angle equal to amount of correction angle equal to amount of correction is removed with is removed with osteotomyosteotomy..

Figure 25Figure 25--24 24 SupracondylarSupracondylar V V osteotomyosteotomy for correction of for correction of valgusvalgusdeformitydeformity. A, Because of shape of . A, Because of shape of medial femur, minor shortening of medial femur, minor shortening of cortex of proximal fragment (cortex of proximal fragment (xx) ) produces sufficient narrowing (produces sufficient narrowing (yy) to ) to allow cancellous penetration on medial allow cancellous penetration on medial side with no lateral openings or side with no lateral openings or translation (B). C, No wedges are taken, translation (B). C, No wedges are taken, and minimal bone removal is required.and minimal bone removal is required.

High Tibial High Tibial OsteotomyOsteotomy (Dome(Dome--shaped)shaped)

Figure 25Figure 25--18 Barrel18 Barrel--vault vault osteotomyosteotomy of of MaquetMaquetuses special jigs to properly orient uses special jigs to properly orient dome dome osteotomyosteotomy. Distal tibia can be translated if . Distal tibia can be translated if needed.needed.

High Tibial High Tibial OsteotomyOsteotomy (Wedge(Wedge--shaped)shaped)

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Figure 25Figure 25--19 19 Medial opening wedge tibial Medial opening wedge tibial osteotomyosteotomy. A, . A, OsteotomyOsteotomy proximal to proximal to tibial tubercle begins 3.5 cm distal to tibial tubercle begins 3.5 cm distal to medial joint line and is directed toward medial joint line and is directed toward proximal tip of fibula, leaving lateral part proximal tip of fibula, leaving lateral part of cortex intact. B, of cortex intact. B, OsteotomyOsteotomy is pried is pried open, and wedgeopen, and wedge--shaped shaped bicorticalbicortical iliac iliac bone grafts are inserted. bone grafts are inserted. OsteotomyOsteotomy is is fixed with plate and screws.fixed with plate and screws.

Figure 25Figure 25--13 13 Fixation of Fixation of valgusvalgusosteotomyosteotomy of of proximal tibiaproximal tibiaby staples just by staples just anterior to fibula.anterior to fibula.

Figure 25Figure 25--14 14 Fixation of Fixation of valgusvalgusosteotomyosteotomy of of proximal tibiaproximal tibia by by lateral contoured lateral contoured TT--plate.plate.

Figure 25Figure 25--16 A, Medial joint collapse resulting 16 A, Medial joint collapse resulting in in varusvarus deformity and medial knee pain. B, deformity and medial knee pain. B, After After high tibial high tibial osteotomyosteotomy..

RA of RA of the Kneethe KneeCharacteristicsCharacteristicsEtiologyEtiologyClinical featureClinical featureRadiologic featureRadiologic feature–– periarticularperiarticular soft tissue swellingsoft tissue swelling–– juxtaarticular osteoporosisjuxtaarticular osteoporosis–– marginal erosion and cystmarginal erosion and cyst–– uniform loss of joint spaceuniform loss of joint space–– marked deformity with subluxation, marked deformity with subluxation,

dislocation, destruction, and fusiondislocation, destruction, and fusion

Pathological featurePathological featureManagementManagement–– conservativeconservative–– surgicalsurgical

PrepatellarPrepatellar Bursitis Bursitis Traumatic Traumatic prepatellarprepatellar bursitis bursitis –– an acute injuryan acute injury, such as a fall , such as a fall

directly on the patella; directly on the patella; recurrent recurrent minor injuriesminor injuries, such as , such as ““housemaid's housemaid's kneeknee””

–– conservative treatmentconservative treatment–– excision of the bursaexcision of the bursa

if fibrosis or synovial thickening with if fibrosis or synovial thickening with painful nodules fails to respond to painful nodules fails to respond to such treatmentsuch treatment

PyogenicPyogenic prepatellarprepatellar bursitisbursitis–– common, especially in childrencommon, especially in children–– unusually largeunusually large–– a careful physical examinationa careful physical examination–– often responds to one or two daily often responds to one or two daily

aspirations, appropriate aspirations, appropriate immobilization, and antibiotic immobilization, and antibiotic coveragecoverage

–– not significantly improved in 36 to not significantly improved in 36 to 48 hours, incision and drainage48 hours, incision and drainage

Figure 24Figure 24--8 Multiple 8 Multiple bursaebursae around around knee that may become acutely or knee that may become acutely or chronically inflamed.chronically inflamed.

PoplitealPopliteal Cyst (Baker Cyst)Cyst (Baker Cyst)Baker in 1877 (Adams in 1840)Baker in 1877 (Adams in 1840)Bursa beneath theBursa beneath the medial head of the medial head of the gastrocnemiusgastrocnemius or in or in the the semimembranosussemimembranosus bursabursa; the latter is a ; the latter is a doubledouble bursa bursa located between the located between the semimembranosussemimembranosus tendontendon and the and the medial tibial condylemedial tibial condyle and between the and between the semimembranosussemimembranosustendontendon and the and the medial head of the medial head of the gastrocnemiusgastrocnemiuseither by either by herniationherniation of the synovial membraneof the synovial membrane through through the posterior part of the capsule of the knee or by the the posterior part of the capsule of the knee or by the escape of fluidescape of fluid through the normal communication of a through the normal communication of a bursa with the knee, that is, either the bursa with the knee, that is, either the semimembranosussemimembranosusor the medial or the medial gastrocnemiusgastrocnemius bursabursaIn childrenIn children

–– the cyst infrequently communicates with the joint, and the cyst infrequently communicates with the joint, and intraarticular pathological findings are rareintraarticular pathological findings are rare

–– simple excision usually are excellent even if incomplete, simple excision usually are excellent even if incomplete, generally resolve with benign neglect, aspiration may be generally resolve with benign neglect, aspiration may be attempted provided the diagnosis is certainattempted provided the diagnosis is certain

In adultsIn adults–– intraarticular pathological findings are common, such as intraarticular pathological findings are common, such as

patellofemoral chondromalacia or a degenerative tear of the patellofemoral chondromalacia or a degenerative tear of the posterior horn of the medial meniscusposterior horn of the medial meniscus

–– recur if the intraarticular pathological condition is not recur if the intraarticular pathological condition is not correctedcorrected

–– If the cyst does not appear to communicate or if significant If the cyst does not appear to communicate or if significant changes cannot be treated arthroscopically, an open changes cannot be treated arthroscopically, an open procedure is indicatedprocedure is indicated

Figure 24Figure 24--11 Removal 11 Removal of midline Baker cyst. of midline Baker cyst. A, Skin incision. B, A, Skin incision. B, After being exposed, After being exposed, pedicle is clamped, pedicle is clamped, ligatedligated, divided, and , divided, and inverted.inverted.

Tibia Tibia VaraVara (Blount Disease)(Blount Disease)ErlacherErlacher (1922) the first description of (1922) the first description of tibia tibia varavara and internal tibial torsionand internal tibial torsionBlount's article (1937) described tibia Blount's article (1937) described tibia varavaraas as ““an an osteochondrosisosteochondrosis similar to similar to coxacoxaplanaplana and and Madelung'sMadelung's deformity but located deformity but located at the medial side of the proximal tibial at the medial side of the proximal tibial epiphysisepiphysis””An acquired disease of the proximal tibial An acquired disease of the proximal tibial metaphysismetaphysis, rather than an , rather than an epiphysealepiphysealdysplasiadysplasia or or osteochondrosisosteochondrosisCause unknown ?Cause unknown ?

–– infection ?infection ?–– trauma ?trauma ?–– avascular necrosis ?avascular necrosis ?–– a latent form of rickets ?a latent form of rickets ?

a combination of hereditary and a combination of hereditary and developmental factors is the most likely developmental factors is the most likely causecauseWeightWeight--bearing, early walking and obesitybearing, early walking and obesityClinical and roentgenographic findings are Clinical and roentgenographic findings are varusvarus and internal torsion of the tibia and and internal torsion of the tibia and genu recurvatumgenu recurvatum

Two Types of Tibia Two Types of Tibia VaraVara<according to age at onset><according to age at onset>

Infantile, begins before 8 years of ageInfantile, begins before 8 years of age–– difficult to differentiate from physiological bowing, especiallydifficult to differentiate from physiological bowing, especially

before the age of 2 yearsbefore the age of 2 years–– infantile tibia infantile tibia varavara is bilateral and symmetrical in approximately is bilateral and symmetrical in approximately

60% of affected children, increases progressively60% of affected children, increases progressively–– physiological bowing is almost always bilateral, tends to resolvphysiological bowing is almost always bilateral, tends to resolve e

with growthwith growthAdolescent, begins after 8 years of age but before skeletal Adolescent, begins after 8 years of age but before skeletal maturitymaturity–– an adolescent form between the ages of 8 and 13 years caused an adolescent form between the ages of 8 and 13 years caused

by partial closure of the by partial closure of the physisphysis after trauma or infectionafter trauma or infection–– ““latelate--onsetonset”” tibia tibia varavara in obese children, especially black in obese children, especially black

children, between the ages of 8 and 13, without a distinct causechildren, between the ages of 8 and 13, without a distinct causehistological changes are markedly similar to infantile tibia histological changes are markedly similar to infantile tibia varavara or or slipped capital femoral epiphysisslipped capital femoral epiphysisasymmetrical compressive shear forces across the proximal tibialasymmetrical compressive shear forces across the proximal tibialphysisphysis promote disruption and cause compression and deviation of promote disruption and cause compression and deviation of normal intercondylar ossificationnormal intercondylar ossification

Tibia Tibia VaraVara (Blount Disease)(Blount Disease)

Medial half of the epiphysis on Medial half of the epiphysis on roentgenogramsroentgenograms

–– short, thin, and wedgedshort, thin, and wedgedPhysisPhysis

–– irregular in contour and slopes mediallyirregular in contour and slopes mediallyProximal Proximal metaphysismetaphysis

–– forms a projection medially (often forms a projection medially (often palpable), but not diagnosticpalpable), but not diagnostic

Medial Medial metaphysealmetaphyseal fragmentationfragmentation–– pathognomonicpathognomonic for the development of a for the development of a

progressive tibia progressive tibia varavaraAngular deformityAngular deformity

–– just distal to the projectionjust distal to the projectionStage VIStage VI

–– the medial portion of the epiphysis fuses the medial portion of the epiphysis fuses at a 90at a 90--degree downward angledegree downward angle

Figure 29Figure 29--39 Diagram of 39 Diagram of roentgenographic changes seen roentgenographic changes seen in infantile type of tibia in infantile type of tibia varavara and and their development with their development with increasing age.increasing age.

Treatment of Blount DiseaseTreatment of Blount Disease

Depends onDepends on–– the age of the childthe age of the child–– the severity of the the severity of the varusvarus

deformitydeformity

Observation or a trial of Observation or a trial of bracingbracing–– between the ages of 2 and between the ages of 2 and

5 years5 years

OsteotomyOsteotomy–– progressive deformityprogressive deformity

Recurrence of the Recurrence of the deformity is not as deformity is not as frequent after frequent after osteotomyosteotomyat an early ageat an early age

Figure 29Figure 29--44 Severe Blount disease. A, 44 Severe Blount disease. A, Closing wedge Closing wedge metaphysealmetaphyseal osteotomyosteotomy. B, . B, EpiphysealEpiphyseal elevation.elevation.

Figure 29Figure 29--45 45 HemicondylarHemicondylar osteotomyosteotomy..