Knee Injuries - Science topic

A variable that is not normally distributed is a dispersed variable and affects the value of the correlation. The greater the dispersion, the lower the correlation, because the correlation depends on the linear relationship between two variables.

@Ganesh S Dharmshaktu sir thank you for your inputs, before the advancement of MR imaging and arthroscopy; the internal derangement of knee in children was generally managed conservatively with rest and immobilization. This has greater advantage for nondisplaced/minimally displaced avulsions of tibial eminence. The risk vs benefit of conservative

approach for ACL injury in children needs to more in attention.

Dear Hakan Arslan

Cycling after a total knee replacement can improve range of motion. This exercise is often included in physical therapy after TKR, as early as the first week after surgery.

Early on, the seat can be raised to limit the amount of bending required. You might only be able to do partial revolutions at first, and this is normal. As motion improves, the seat can gradually be lowered.

Cycling for range of motion is performed slowly, pausing at the top to stretch into bending, and at the bottom of the revolution to stretch into extension — a straight-knee position. During the range of motion phase, there is no added resistance on the bike.

Avid exercisers may be accustomed to moderate to high-intensity workouts. However, for patients who have recently undergone a total knee replacement, it is important not to over-exert initially.

At first you have to be sure there is no injuries due to a luxation (you have to check the arteries, high risk of postop. compartment syndrome!).

Then I would reconstruct the MCL with internal ligament bracing (suture tapes with anchors if available). If PCL is completely instable and you have enough OR time, then I would recommend to reconstruct the PCL with Quad tendon in one session. Otherwise you can stabilize the PCL with a brace.

I do not think that full ligament repair of MCL + PCL + ACL in one session is recommended.

And what about cartilage an meniscus??

The standard method by identifying semiT or gracilis on flexed knee is followed by a mini incision followed by use of tendon stripper to obtain desired tendon part. The muscles and attached soft tissue is removed manually and desired bundles are created with use of ethibond as suture material over a tendon board.

AM

Thank you very much Gustavo! 

I understand now.This topic is important intraop during TKA and when you explore a patient in the office ( TKA stability).I will try to read the articles above.Thank you!

I think you would not find on curling. But nothing prevents you from seeking other similar work areas curling. As carleur who always work knee flexed. It will be in the occupational disease.

We used trypsin to degrade cartilage. Usually put a small sample into 0.1 mg/ml trypsin solution more than 8 hours. but you might use higher concentration trypsin.

In completely non-displaced patella fx's, I keep patients in a ROM brace x 3weeks locked in full extension, allowing for showers, bathing, etc.  Range of motion 0-30 at 3- 6 weeks, then progress as tolerated. 

Check out http://www.klokavskade.no/en/Project/

It is not surprising to find degenerative changes of ACL in young athletes. Furthermore, if such changes exist this makes ACL more vulnerable because its strength, elasticity and durability reduce. So in similar cases further training in elite sports should be seriously discussed. Perhaps, change of sports kind should be considered, i.e. from athletics to swimming. 

Hi Peter,

Very informative..... Thanks a lot.

Warm regards,

If we presume that no malunion with a major angle between the fragments in the sagittal plane exists, then arthrolysis (adhesions release) followed by systematic rehabilitation should yield good functional results. 

From the information provided it is impossible to make a proper diagnose. Yes, patient needs further examination, by both MD (to exclude structural damage such as fractures of the bone's (often gives nightly and progressiv pain, worsen in weight bearing), ligamentous tears etc.) and by an osteopath (for pain caused by e.g. fascial tention, blocked joints, compromised biomechanics etc). There are several

possibilities for the cause of the pain. Biomechanically the impact through the femour might have caused the ili to fixate postriorly, this may creates pain in both SI-joint, pelvis, buttocks and lumbar spine. Displaced/fixed sacrum can irritate e.g. the m. piriformis createing entrapments for vessels and nerves for lateral thigh --> pull on lateral knee (and others). The possibilities are many. Proper investigation is necessary.

Usually clinically we do patellar grinding test to assess for patellofemoral degeneration. persistant pain while squatting,kneeling and getting up from sitting position are more linked with patellofemoral altered kinetics. Patellar crepitus must be differentiated from patellar snaps or clunk as it indicates joint degeneration moderate to severe.

Yes, Dietrich, you are right. The idea of arthritic joint distraction is to overcome contractures. As far as knee osteoarthritis is concerned, ligamental instability is a feared effect. Especially, in frontal plane deformities.  Nevertheless, this publication by Wiegant et al (the Netherlands) (s. below) reports interestingly good results with distraction.

After the surgery, the patient should have a knee cast in full extension, bearing according to the pain and contracting the quadriceps muscle for 10 to 12 days (until the removal of the sutures). In this period the knee get used to the new situation and we avoid excessive unpleasant inflammation. After that the patient should unblock the cast in order to start normal range of motion and should take it to realize some passive exercises of flexing and extended the knee with the help of the contralateral limb seated. In one month patient should flex more than 90º passively and actively. 

Dear Awais

Stainless steel and chrome cobalt are the routine material in orthopedic implant . but hip and knee systems for arthroplasty  had more complex structures. stems usually sprayed with Tivanium 6Al 4V for biologic osteointegration. in some designs porous coated and etc..

I agree with Dr. Farouk. This injury lies back more than a year and the fragments are severely dislocated. The fragments are osteoporotic.  One can try to  mobilise the quadriceps muscle in an attempt to reduce the non-united fragments and fix them but in my opinon this should be difficult if possible at all.

One should then consider patellectomy, quadriceps plasty and transposition of part of the ischiocrural muscles to enhance the extension mechanism. In my practice this prosedure has worked satisfactorally.

Crepitation suggests sever chondromalacia (gr II and III). I have no experience with the measuring the level of destroying enzymes.

Fairly standardized calculation as soon as you identify what the gold standard of change is. 

If you mean eversion of the patella together with the extensor apparatus at knee surgery, there seems to be some evidence, that in all these cases the postoperative flexion is diminished.

Personally I see no difference between cases, where we everted the patella and cases where we did not.

Subhash,

we tested PHB/HAp scaffold for bone and UHMWPE implant for cartilage defects replacement. But the last one was not porous.

In case of PHB/HAp there were sites of neo-osteogenesis after 3 weeks of orthotopic transplantation in rats bone. Over time there was resorption of the material and replacing it with bone. 

Dear all, if you want to look at what causes anterior knee pain you will need to conduct a prospective study with asymptomatic subjects that you follow over time. Looking at patients already in pain makes it impossible to determine if lumbosacral ROM is the cause or the effect of pain.

Dear Reda

This article may be useful for you

J Orthop Res. 2008 Jun;26(6):793-9. 

Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion.

Peeler J1, Anderson JE.

Abstract

Rehabilitative protocols and orthopadic research are significantly influenced by the ability to perform reliable measures of specific physical attributes or functions. The hypothesis was that the Ely's test for evaluating rectus femoris flexibility and joint range of motion (ROM) is a reliable clinical tool. Participants (n = 54) were between the ages of 18 and 45, and had no history of trauma. Three clinicians with orthopedic expertise assessed quadriceps flexibility and joint ROM using pass/fail and goniometer scoring systems. A retest session was completed 7 to 10 days later. Statistically, Kappa values for pass/fail scoring (intrarater $\bar {X}=0.52$, interrater $\bar {X}=0.46$) and ICC values (intrarater $\bar {X}=0.69$, interrater $\bar {X}=0.66$) for goniometer data both indicated that the Ely's test demonstrated only moderate levels of intra- and interrater reliability. Measurement error values (SEM = 4 degrees , ME = 4 degrees , and CV = 3%) and Bland and Altman plots (with 95% Limits of Agreement) further demonstrated the degree of intrarater variance for each examiner when executing the Ely's test in a clinical setting. Results call into question the statistical reliability of the Ely's test, and provide clinicians with important information regarding the reliability limits of the Ely's test when used to clinically evaluate flexibility and joint ROM in a physically active population. More research is required to determine the variables that may confound statistical reliability of this orthopedic technique that is commonly used in a clinical setting to assess function about the thigh region.

I do have considerable experience with trochleaplasty but feel that it is not indicated in grade 1dysplasia.  I therefore agree with a combined TT Transfer with MPFL Reconstruction in this patient. 

Dear Khalil, In PFPS, the pattern of muscle weakness may differ patient to patient. Before comparing the intervention it is essential to identify weak group of muscle. In patients without weakness of hip abd/ ext, it may not be effective with strength training. If the aim is to correct the biomechanics I would recommend to strengthen all 3 muscle. Also finding the tight muscle group and releasing it would heighten the pain management strategy in PFPS...

Dear Dhara,

The ultimate goal of exercise in OA is to prevent or delay disability. An exercise program should incorporate elements to lessen pain during activity and to

increase or at least maintain joint range of motion, periarticular muscle strength, joint stability, and aerobic capacity or level of conditioning.

Exercise in OA should be adapted according to the presence and severity of pain.

In painful episodes:

- Isometric exercise or exercise in a non weight-bearing

(e.g., biking, rowing with adapted tools) or

- In a partial weight-bearing position (e.g., aquatic ex) should be recommended.

In painless (or at least less painful) periods:

- Exercise program may include progressive muscle performance exercises.

The above exercise programs may delay disability but does not help regenerationof the cartilage. Hence, it can't recover the actual joint pathology, so the final choise of treatment will remain joint reconstruction or replacement surgery untill we get a new line of treatment.

Regards

I often prefer drilling with a 2.5 mm sheath pin at low speed. The defects which are not approachable by the pin, I use microfracture awl, for example most of the tibial defects.

Although it is advocated to keep them non weight bearing for 6-8 weeks, I however, start early weight bearing. I have, although, not performed a histopathology to see the quality of cartilage, a second look arthroscopy due to some other problem, in some patients showed filling of the defects with new cartilage like tissue.

My common indications these days for this procedure is to do it as a part of arthroscopic debridement in elderly patients for osteoarthrosis who are still not the candidates for arthroplasty due to various reasons. The results are satisfactory.

Dear Julie

Quadriceps angle (Q)

• It is the angle between the straight lines: 1) which pass through the patellar and tibial tuberosity and 2) the middle patella and the iliac crest Top Previous

• It is larger in women, since they have greater horizontal distance between iliac crest.

Limits for Men and Women

• Men: 11 to 17 degrees

• Women: 14 to 20 degrees

• Values ​​outside these limits are considered pathological burden and all structures involved joint (knee and hip).

These articles may be useful for you:

1) Biomed Tech (Berl). 2013 Sep 7

The Q-Angle and its Effect on Active Knee Joint Kinematics - a Simulation Study.

Asseln M, Eschweiler J, Zimmermann F, Radermacher K

2) J Orthop Res. 2001 Sep;19(5):834-40.

Q-angle influences tibiofemoral and patellofemoral kinematics.

Mizuno Y1, Kumagai M, Mattessich SM, Elias JJ, Ramrattan N, Cosgarea AJ, Chao EY

3) Does the change in Q angle magnitude in unilateral stance differ when comparing asymptomatic individuals to those with patellofemoral pain?

Herrington L.

Phys Ther Sport. 2013 May;14(2):94-7

4)The relationship between quadriceps angle and tibial tuberosity-trochlear groove distance in patients with patellar instability.

Cooney AD, Kazi Z, Caplan N, Newby M, St Clair Gibson A, Kader DF.

Knee Surg Sports Traumatol Arthrosc. 2012 Dec;20(12):2399-404

5) Normal Q-angle in an adult Nigerian population.

Omololu BB, Ogunlade OS, Gopaldasani VK.

Clin Orthop Relat Res. 2009 Aug;467(8):2073-6

Dear Ravi

Below comments from Bernard R. Bach, MD, - What Do You Do If You Drop the Graft on the Floor? Healio Orthopedics.

Great care must be taken to avoid contamination during harvest and or preparation of the graft for anterior cruciate ligament (ACL) reconstruction. Our protocol emphasizes that the surgeon who harvests the graft personally walks the tissue to the back table to reduce the risk of dropping the graft. Handing off of a freshly harvested graft to other members of the surgical team for preparation simply increases the likelihood dropping the graft. With this protocol, the senior author has not dropped any grafts in over 20 years of practice, including more than 1700 knee ligament procedures. Careful attention must be paid during preparation on the back table as well. The fully prepared graft is placed in a marked kidney basin. All operative personnel are informed to prevent the graft from being inadvertently passed off the sterile field

When the graft is brought to the operative field for graft placement, if it is wrapped in a laparotomy sponge, theoretically the only contaminated portion would be the sutures extending beyond the sponge if the graft were dropped.

If the graft is dropped, the salvage falls into one of several possible categories, namely cleaning the graft, using an alternative graft (auto or allograft), or stopping the procedure and completing the surgery at another time with a different graft.

One study showed a 58% rate of positive culture when the graft was dropped and left on the operating room floor for 15 s. Molina et al have shown that a 90-s soak in chlorhexadine gluconate is the most effective method to resterilize the graft

Another report found that a 30-min soak in 4% chlorhexadine followed by a 30-min soak in triple antibiotic solution (gentamicin, clindamycin, polymixin), followed by sterile saline wash was 100% effective in sterilizing contaminated rabbit patellar tendon grafts. In that same study, 10% povidone-iodine was 100% ineffective, as was triple antibiotic soak used in isolation.

A survey of sports medicine specialists found that most would choose cleansing the graft to manage the problem of a dropped graft. Forty-three surveyed surgeons reported having cleansed a contaminated graft and none reported postoperative infections.3

Another option is choosing an alternative graft. This requires preoperative consent from the patient or intraoperative consent from a family member and may be problematic for a patient who expects one graft type but ends up with another. Some surgeons routinely consent their patients for the use of an allograft should the autograph become contaminated or otherwise compromised. Again, if this option is selected, preoperative discussion with the patient is best because cultural or religious beliefs may preclude the use of cadaveric tissue.

Our preference would be cleansing the graft using a 30-min soak in 4% chlorhexadine gluconate followed by lavage with sterile saline, then another 30-min soak in triple antibiotic solution (0.1% gentamicin, 0.1% clindamicin, 0.05% polymyxin) and another sterile saline wash. Washing the chlorhexadine is crucial because chlorhexadine-induced chondrolysis has been reported.4 While this protocol is time consuming, it has solid scientific backing and would allow one to proceed with the same graft as planned preoperatively. One could consider a course of postoperative antibiotics, although we would refrain from this as it would likely only mask an underlying infection, delaying its definitive treatment. In addition, we recommend full disclosure to the patient regarding the incident and the low likelihood of any residual difficulties.

References

1. Molina ME, Nonweiller DE, Evans JA, DeLee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373-378.

2. Goebel ME, Drez D Jr, Heck SB, Stoma MK. Contaminated rabbit patellar tendon grafts: in vivo analysis of disinfecting methods. Am J Sports Med. 1994;22:387-391.

3. Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348-1353.

4. Van Huyssteen AL, Bracey DJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81-B:995-996.

While there may be general assumptions made that the whole knee is susceptible for OA, the assumption is misleading and not well substantiated. The evolution of the OA lesion is almost always focal, beginning in a single joint compartment. The problem arises focally as a result of multiple factors which represent the imbalance between the most important mechanical factors, which are both dynamic (eg adduction moment) and static, (eg varus alignment), and biological (eg metabolic as alluded to above). Weak tissues are more susceptible, strong, well aligned limbs in slim individual are less at risk. Once the process starts all parts of the knee as joint structure become involved....the driving forces for progression are dominated by mechanical factors.

For more thoughts on this topic please visit www.oaisysmedical.com and look at 'Knee Pain; arthritis?"'

Dear Gustavo

Criteria are:

1. Age of patient

2. Time of injury (Acute or Chronic)

3. Area of injury

4. How extended is the injury

5. Complexity of injury

6. Activity of patient

So young active patient with acute extended unstable tear of meniscal injury situated in the red zone mainly and without ligament injuries (or injuries that are planned to be repaired or reconstructed during surgery), would be better to have this fixed.

This is a very difficult question. The "simple" answer would be that arthrolysis is rarely indicated in the era of joint replacement surgery. But the context of the question is different. It is well known that exact and perfect reduction of intraarticular fractures of the knee is not always possible. Haemarthrosis, loose bone fragments, soft-tissue damage, malunion, etc. make the recovery of optimal ROM problematic. In any case early kinesitherapy should be initiated as soon as possible. Close follow of the development of joint mobility is advisable too. In my opinion revision surgery (incl. arthrolysis) should be decided individually from case to case.Of course, haemarthrosis should be treated early on emergency base.

In any case, fracture healing should be the primary goal. When the fracture heals and the ROM is unacceptable, then there is a vast range of options including arthrolysis, arthrodesis, and last but not least TKA.

There may be lot of reasons for patellofemoral pain,if the position of the patella is the one causing pain,corrrection of the position by taping helps a lot followed by strengthening of quadriceps,hamstrings and hip abductors will help a lot to relieve pain.

Aircast has a device called the Rolimeter (see http://www.genourob.com/de/arthrometer/7-arthrometres/44-le-rolimeter-.html) that is not very expensive and is easy to use for A-P knee laxity (i.e. drawer test). I am not sure if it would work but maybe there is a way to use it (against its dedicated purpose) for M-L laxity test.