Definition:The knee joint is largest joint and most complex joint of the body .

Actually consisting of three joints within a single synovial cavity. 1-laterally is a tibiofemoral joint (modified hinge
joint) 2-medialy too 3-an intermediate patellofemoral joint between patella and patellar surface of femur (planar joint)

1- articular capsule:- not complete, the ligamentous sheath surrounding the joint consist mostly of muscle, tendon and their expansions. 2- medial and lateral patellar retinacula: fused tendons of insertion of the quadriceps femoris muscle and the fascia lata (deep fascia of thigh) that strength the anterior surface. 3- patellar ligament. 4- oblique popliteal ligament. 5- medial collateral ligament. 6- lateral collateral ligament.

7- intracapsular

ligament :

A.

anterior cruciate ligament (ACL)

Extend posteriorly and laterally from a point anterior to the intercondylar area of the tibia to the posterior part of medial surface of the lateral condyle of the femur. The ACL limits hyperextension of the knee and prevent the anterior sliding of the tibia on the femur. This ligament is stretched or torn in about 70% of all serious knee injuries. B. Posterior cruciate liagment (PCL) Extend anteriorly and medially from a depression on the posterior intercondylar area of the tibia, and lateral meniscus to the anterior part of the lateral surface of the medial condyle of the femur. The PCL prevent the posterior sliding of the tibia on the femur, especially when the knee is flexed. This is very important when walking down stairs or a steep incline.

8- articular discs (menisci):

two fibrocartilge discs between the tibia & femural condyles.

A.

B.

Medial meniscus. Semicircular piece of fibrocartilage (C-shaped). Lateral meniscus. Nearly circular piece of fibrocartilage (approaches an incomplete O in shape). The medial and the lateral meniscus are connected to each other by the transversa ligament and to the margins of tha head of the tibia by coronary ligaments.

The meniscus is a half moon shaped piece of cartilage that lies between the bearing joint surfaces of the femur and the tibia. Roles of Menisci:

*Increasing stability of knee.

*Control rolling and gliding actions of the knee.

*Common

among young active adults.

*Longitudinal split because of the big force grinding it between the femur and the tibia, because of the bearingweight nature of the knee joint. *Common in Football players: flexion of knee joint in addition to twisting. *Little force is needed in middle aged, because fibrosis restricts mobility of meniscus.

*Medial Menisci: more prone to injury because of its restricted anatomy due to attachment to the joint capsule make it less mobile.

 Classification

according

to Mechanism ( traumatic Vs degenerative) Pattern of tear ( bucket handle Vs horizontal. ).

Patterns of tears:
*Bucket-Handle Tears:
The split is vertical, along the circumference of the meniscus leaving anterior and posterior segments attached loosely. Sometimes the torn part displaces towards the center, causing locking (extension block).

Horizontal tears:
*Usually degenerative in origin or due to repetitive minor trauma, or with association with meniscal cysts. *Generally speaking, most of the meniscus is avascular, except the outer third-from capsule-, due to this spontaneous repair doesnt occur.
The loose part act as a mechanical irritant causing recurrent synovial effusion, and in severe cases secondary osteoarthritis.

Clinical Features:
Severe Pain preventing further activity. Swelling appears some hours later or even the following day. Knee is locked in partial flexion *With rest, pain and swelling may subside, may recur after twisting or strains followed again by pain and swelling. In ptn >40yrs the main complaint is recurrent giving way or locking

 *O/E Joint

held slightly flexed Joint effusion may be present In late cases quadriceps are wasted Joint line tenderness (Mostly medial) Flexion is full , extension limited Apleys test - positive

Imaging
X-ray Normal MRI most useful may reveal tears missed by arthroscopy

Arthroscopy : Diagnostic and therapeutic.

You have to be certain that the lesion you can see is the one causing the patients symptoms. Treatment
Most meniscal tears do not heal without intervention. If conservative treatment does not allow the patient to resume desired activities, occupation, or sport, surgical treatment is considered. Surgical treatment of symptomatic meniscal tears is recommended because untreated tears may increase in size and .may abrade articular cartilage, resulting in arthritis

Treatment Conservative treatment of meniscal injuries begins with RICE (Rest, Ice, Compression, and Elevation). Arthroscopy is the preferred method peripheral tears surgery The displaced portion should be excised
Postoperative

physiotherapy

 Anatomy of patella Soft tissue elements affecting the patella are the stabilizing capsular and ligamentous structures within which the patella lies. Some ligaments of the knee are continuous with the fibrous capsule surrounding the patella.

When injuries occur, all structures are simultaneously affected. These ligaments hold the patella in place during static and dynamic phases.

The knee is normally in slight valgus so there is a natural tendency for the patella to pulled to the lateral side when the quadriceps muscle is contracted Traumatic dislocation is due to sudden sever contraction of the quadriceps muscle while the knee is stretched in valgus and external rotation. The patella dislocates laterally and the medial retinacular fibers may be torn 15-20. % of patient with patellar dislocation will have recurrent episodes. It may develop without initial trauma

The

predisposing factors are :

1- generalized ligamentous laxity . 2- under development of lateral femoral condyle and flattening of the intercondyler groove. 3- maldevelopment of the patella;too high or to small . 4- valgus deformity of the knee. 5- primary muscle defect.

Females > males . Often bilateral c/o: -acute pain :tearing sensation - knee is stuck in flexion and the patient may fall. Often the patella is repositioned spontaneouslly - if the patella remain unreduced Medial mass because the uncovered medial femoral condoyle stand out prominently- NOT THE PATELLA-. no active or passive movement is possible On exam : - Tenderness on the medial side of the joint. - Swelling . - Aspiration may reveled a blood stained effusion . positive Apprehension test.

X-ray (includes anteroposterior, true lateral, and axial or sunrise views ( CT scan MRI

Apprehension sign. The knee is placed at 30 flexion, and lateral pressure is applied. Medial instability results in apprehension by the .patient

lateral patellar dislocation (arrows)

Complications : -Repeated dislocation damage the contiguous surface of patella and femoral condyle which lead to further dislocation -later Secondary OA. Rx: If still dislocated : PUSH IT BACK ( gently) + cylinder plaster or splint is applied for 2-3 weeks + quadriceps strengthening exercise for 3 months. In children : The patellar mechanism tends to stabilize as the child grows but 15% of these children will suffer from repeated attacks which will be an indication for surgery . Role of surgery in recurrent patellar dislocation : 1- to repair or strengthen the medial patellofemoral ligament . 2- to realign the extensor mechanism.

 Osteoarthritis

is a chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins ( osteophytes) and capsular fibrosis. It is defined as primary when no cause is obvious and secondary when it follows a demonstrable abnormality.

 OA

is the most common joint disease of humans. Among the elderly, knee OA is the leading cause of chronic disability in developed countries. Risk factors: 1- age . 2- Racial difference. 3- 2ndy cause e.g hx of trauma . 4- obesity. 5- family Hx.

The knee is the commenest site for OA Predisposing factor: 1. Injury to articular surface 2. Torn meniscus 3. Ligamentus instability 4. Pre-existing deformity of the knee. In many cases no obvious cause can be found and here the condition is usually bilateral and ass. w/ heberdens nodes

A. Trauma
1. Acute 2. Chronic (occupational, sports)

D. Endocrine
1. Acromegaly 2. Hyperparathyroidism 3. Diabetes mellitus 4. Obesity 5. Hypothyroidism

B. Congenital or developmental

1. Localized diseases: Legg-CalvePerthes, congenital hip dislocation, E. Calcium deposition diseases 1. Calcium pyrophosphate dihydrate deposition slipped epiphysis 2. Mechanical factors: unequal lower 2. Apatite arthropathy extremity length, valgus/varus F. Other bone and joint diseases deformity, hypermobility syndromes 1. Localized: fracture, avascular necrosis, infection, 3. Bone dysplasias: epiphyseal gout dysplasia, spondyloepiphyseal 2. Diffuse: rheumatoid (inflammatory) arthritis, Paget's disease, osteopetrosis, osteochondritis dysplasia, osteonychondystrophy

C. Metabolic
1. Ochronosis (alkaptonuria) 2. Hemochromatosis 3. Wilson's disease 4. Gaucher's disease

G. Neuropathic (Charcot joints) H. Endemic

1. Kashin-Beck 2. Mseleni I. Miscellaneous 1. Frostbite 2. Caisson's disease 3. Hemoglobinopathies

 Osteoarthritis

results from a disparity between the stress applied to articular cartilage and the ability of the cartilage to withstand that stress . This could be due to one or combination of two processes: 1- weakening of the articular cartilage(genetic defect in collagen type ll or inflammatory disorder e.g RA). 2- increased mechanical stress in some parts of the articular surface. -excessive impact -reduction of the articular contact area

Remodeling and hypertrophy of bone are major features of OA. Appositional bone growth occurs in the subchondral region, leading to the bony "sclerosis" seen radiographically. The abraded bone under a cartilage ulcer may take on the appearance of ivory (eburnation). Growth of cartilage and bone at the joint margins leads to osteophytes (spurs), which alter the contour of the joint and may restrict movement. A patchy chronic synovitis and thickening of the joint capsule may further restrict movement. Periarticular muscle wasting is common and may play a major role in symptoms and, as indicated above, in disability.

 The

cardinal features are: 1- progressive loss of cartilage thickness. 2- subarticular cyst formation and sclerosis. 3- remodling of the bone ends and osteophyte formation. 4-synovial irritation. 5- capsular fibrosis.

OA

and synovitis:

OA NOT primarily an inflammatory disease shedding of fragment from articular cartilage and release of enzymes from damaged cells

Cause

of Pain:

articular cartilage and synovium VS bone and capsule

 c/o:

middle age patient complain of pain starts insidiously and increase slowly over time ( months and years ) aggravated by exertion and relieved by rest, with time relief is less and less complete. Stiffness :mainly after rest Symptoms follow an intermittent course with periods of remission lasts for months In advance stage : deformity ,swelling, muscle wasting and loss of mobility . No systemic manifestations in contrast to inf. diseases.

 1-

narrowing of joint space. 2- subarticular cyst formation and sclerosis. 3- osteophyte formation. 4- evidences of 2ndry causes e.g. old fracture.
The first two are restricted initially to the major load-bearing part of the joint but later the entire joint is affected.

Early : symptomatic 1- relieve the pain .( NSAIDs) SE?. 2- join mobility (physiotherapy). 3- reduce load ( walking stick, soft soled shoes,wt reduction and avoid stressful activity ). Intermediate: If symptoms increase despite conservative treatment some form of operative treatment may be needed such as joint debridement: removal of interfering osteophytes and cartilage tags and loose bodies realignment osteotomy why? Late: Surgical intervention Total Knee Arthroplasty (TKA)

 The

primary indication for TKA is to relieve pain caused by severe arthritis. The pain should be significant and disabling. Night pain is particularly distressing. If dysfunction of the

knee is causing significant reduction in the patient's quality of life, this should be taken into account. Correction of significant deformity is an important indication but is
rarely used as the primary indication for surgery.

Exhaust all conservative treatment measures before considering surgery .

 Valgus

stresses are resisted by the fascia lata, pes anserinus ,MCL and the posteromedial part of the capsule. Varus:illiotibial tract and LCL ACL & PCL provide both anteroposterior and rotatory stability and help to resist excessive vulgus and varus angulation

 History

of twisting or wrenching injury or claim to have heard a pop as the tissue snapped Knee is painful Immediate swelling Tenderness is most acute over the torn ligament. Stressing one or other side of the joint may produce excruciating pain

 Tests

for ligamentous instability can be preformed if pain allows Partial tears permit no abnormal movement Complete tears permit abnormal movement, sometimes surprisingly causing little pain. Doubt about the diagnosis indicates examination under anesthesia

 Sideways

tilting (valgus and varus) is examined with the knee at 30 of flexion then with the knee straight Movement is compared with the normal side If the knee angualtes only in slight flexion there is probably an isolated tear of the collateral ligaments If it angulates in full extension there is almost certainly a rupture of the capsule, cruciate and collateral ligaments

 Anteroposterior

stability is assessed first by placing the knees at 90 with the feet resting on the couch and looking from the side for posterior sag of the proximal tibia, when present this is a reliable sign of PCL instability A positive drawer test is diagnostic of a tear but a negative does not exclude one The Lachman test is more reliable; the anteroposterior glide is tested with knee flexed at 15-20.

drawer test

Lachman test

 Stress

x-rays may provide evidence of instability Plain x-rays may show that the ligament has avulsed a small piece of bone:-The MCL usually from the femur -LCL from the fibula -ACL from the tibial spine -PCL from the back of the upper tibia

 Intact

fibers splint the torn ones and so spontaneous healing will occur Adhesions may result, so active exercise is prescribed Aspirating the haemarthrosis and applying ice packs intermittently relieves pain Weight-bearing is allowed Knee is protected from rotation or angulation strains by a heavily padded bandage or a functional brace

Isolated MCL or LCL treated as above Isolated tears of ACL may be treated by early operative reconstruction if the individual is a professional sportsman Cast-brace is worn until symptoms subside, thereafter movement and muscle-strengthening exercise. This is sufficient in about half of the patients as they regain good function and need no further treatment. Remainder will have varying instability, late assessment will identify those who will benefit from ligament reconstruction. Isolated tears of the PCL are usually treated conservatively

 Sometimes

a severe strain instead of rupturing a cruciate ligament results in an avulsion fracture at the insertion of the ligament. The fragment may only be partially displaced and difficult to detect on x-ray. If the fragment can be manipulated back into position and allow full extension of the knee, immobilization in a plaster cylinder for 6 weeks will suffice Otherwise operative reduction and fixation (sutures or screws) and a plaster cylinder for 6 weeks will also be needed Full movement is usually regained in 3 months

 In

ACL and collateral ligament injury treatment starts with joint bracing and physiotherapy to restore a good range of movements before ACL reconstruction Combined injuries involving the PCL the same approach is used however all damaged structures need to be repaired

Adhesions If the knee with a partial ligament tear is not actively exercised, torn fibers will stick to intact fibers and bone. The knee gives way with catches of pain, localized tenderness and pain on lateral or medial rotation occur Confusion with a torn meniscus can be resolved by the grinding test or arthroscopy

Instability The knee continues to give way and tends to get worse predisposing to osteoarthritis. Reconstruction before degeneration is wise.

D1