Anatomy: hinged joint, with intial and final rotation (5)

Articulations: patelo-femoral, femoro-tibial (medial, lateral joint space)

Muscles ligaments: stabilizers of the knee
Examination:
Patients history Complaints:
Pain : diffuse or localised,with movements (weight bearing) only or resting
pain
Swelling: diffuse or localised, with fluctuation and balloting of patella
Stiffness limitation of motion early morning (inflammatory disorder), or
after inactivity (osteoarthritis)
Locking (something is jammed between joint surfaces torn meniscus)
inability to extend the knee
Deformity unilateral bilateral, varus valgus flexion, extension
Giving way ligamentous injury- sign of instability
Loss of function difficulty in moving, walking stairs, diminishing walking
distance
Look: position of knee (partially flexed extended, varus- valgus), wasting of
muscles (measuring girth of thigh)
See patient standing and lying supine
Feel: swelling, tenderness, warmth,crepitus
Move: flexion, until calf meets thigh, slight hyperextension.
Patellar tests;
Patellar friction test pressing patella against femur
Patellar apprehension test: pressing the patella laterally, while flexing the knee if
patella subluxates or is likely to dislocate, sudden muscel spasm is provoked
Stability tests:
Medial collateral test knee in valgus stress
If varus stress applied: lateral collateral test
Anterior + posterior drawer signs
Imaging techniques:
X-ray: all 3 joint spaces to be viewed
MRI : condition of soft tissues tears, tumors, cysts, condition of subchondral bone
Knee Arthroscopy: Introduction mostly lateral to lig. patellae
Torn medial meniscus: bucket handle shape:
Shaver in use: torn part of anterior cruciate ligament is removed
Arthroscopic view of chondromalatia probe leaves a deep indentation on joint
surface

Genu varum: bow legs Blounts disease (tibia vara)

Genu valgum: knock-knees
Look:
Shape of knee
Intermalleolar distance
X-ray: condition of joint surface
Genu valgum: Operation: in child blocking of medial side of growth plate with
staples
In adults: femoral osteotomy (supracondylar)
Corrective osteotomy in genu varum and genu valgumafter skeletal maturity
Prerequisite: joint surface is intact (on x-ray)
Site of correction:
In varus deformity on the proximal tibia (below the knee)
In valgus deformity on the distal femur (above the knee)
Operation of genu valgum in adults: supracondylaer varus osteotomy of femur
Genu varum with intact joint surface:
Corrective operation: high tibial osteotomy (above the tibial tuberosity)
Genu varum in adults due to osteoarthritis of medial joint compartement:
Operation: hemiarthroplasty (unicompartemental knee replacement UCP)
Cysts of the knee:
Bakers cyst (in children) preformed cyst in the popliteal fossa (usually
from the semimembranous bursa)
Popliteal cyst (in adults) joint fluid is produced by arhritis, pumped into
popliteal fossa
Treatment:
in children remove cyst ( risk of damaging neuro-vascular structures of the
popliteal fossa!)
In adults: treat the underlying disorder (usually osteoarthritis of the knee)
remove cyst only, if it is too large
Remove cyst, if it compresses the popliteal vein
Chondromalatia patellae:
In severe cases: decompression of patello-femoral joint
Lateral release: cutting through vastus lateralis fascia, by this way
reducing compressive forces on patella
Osteotomy of tibial tuberosity: advancing tuberosity- cutting and putting
bone graft in order to lift up the tuberosity, and reduce lever arm

Patello-femoral disorders:
Chondromalatia patellae: typical source of anterior knee pain in adolescent girls
Biomechanics: in patello-femoral joint forces are 25x body weight, when standing
up from squatting positiion
Symptoms: pain behind patella when sitting for a long time
Arthroscopic view: softening of chondral surface of patella
Treatment: chondroprotective drugs
Forces acting at patello- femoral joint 25 x body weight!!
Patello-femoral arthrosis with lateral hyperpression syndrome
Treatment: lateral release cutting through thick lateral soft tissues
Osteochondritis dissecans of femur condyle

Popliteal cyst:
Baker-cyst in juveniles (congenital disorder, typical in childhood
In advanced age: popliteal cyst, caused by increased intraarticular fluid (eg. in
osteoarthritis)

Osgood- Schlatters disease

Traetment: restrict sporting activities, until symptoms subside
In extreme cases: if tibial tubercle is torn off (avulsed) fixation with resorbable pin
Recurrent (habitual) dislocation of patella
Direction of dislocation: lateral
Predisposing causes:
Dysplasia of lateral femoral condyle (condyle is flat)
Thick band in vastus lateralis fascia (lateral band)
Sign: apprehension test
X-ray: typical in skyline view (tangential view of the knee
Typical x-ray presentation: maltracking of patella (not fitting anatomically
into the patellar groove of the femoral condyle)
Treatment of habitual (recurrent) dislocation of patella: if occurs more,
than once, operative
Operation: medialisation of ligamentum patellae

Medialisation of ligamentum patellae:

Using soft tissues release of thick lateral band (part of iliotibial tract) and
using part of the extensor ligament to pull the patella medially
Tibial tuberosity transfer cutting out the tibial tubercle, putting it
medially and fixing it with a screw
Osteoarthritis of knee
Signs: pain,stiffness, effusion (fluid in the joint, due to synovitis)
Difficulties in walking (like in hip OA)
X-ray typical changes in all 3 compartments of the knee (patello-femoral, medial
and lateral femoro-tibial joint space

OA (osteoarthriitis) of knee:
narrowing of the joint spaces
osteophytes,
subchondral sclerosis
(typical signs of osteoarthritis in any joint!)
Typical x-ray changes in knee osteoarthritis: medial joint space disappeared (varus
gonarthrosis!) knee in varus
Clinical view: varus knee (especially on the right side)
Osteoarthritis of knee Treatment:
Conservative: if pain is not too severe
Rest
Antiinflammatories
Physio (iontophoresis etc)
Intraarticular steroid: mostly incases, where no operation is planned (risk of
infection!)
Joint preserving procedures: if varus or valgus deformity is present, and no
severe signs of arthritis are present corrective osteotomy
Valgus osteotomy of tibia in varus knee, varus osteotomy of femur in valgus
knee
Replacement of cartilage surface of femoral condyle
Mosaic plasty (Hangody plasty)
TISSUE ENGINEERING - TISSUE CULTURES
Osteochondral mosaic plasty (Hangody- plasty) for circumscribed chondral
defects(max. 4cm diameter)
Microfracture of chondral defects drilling holes into subchondral
bone, into bleeding surfaces- regeneration of fibrous cartilage is
expected to happen
Osteoarthritis of knee treatment:
Knee prosthesis knee replacement: in advanced forms of osteoarthritis
Two types:
Hemiarthroplasty only one joint compartment is replaced (usually the
medial compartment)
Total knee replacement (TKR) all 3 compartments are replaced
Xray Total knee replacement: all 3 compartments are replaced (cement t is used in
most cases to fix the implants to the bone)
Anterior Cruciate lig. has to be sacrificed (always)
Metal on polyethylen prosthesis

Intact collateral ligaments are essential

Posterior cruciate may be sacrificed too, slightly diferent design is necessary
Total knee replacement: posterior cruciate ligament is sacrificed in cases of severe
flexion contracture
Functional result:
135 flexion, stable knee
New ways higly desorganised knee, no collateral ligaments- REVISION
PROSTHESIS
Rheumatoid Arthritis 62 yrs
Varus 30
Severe bone destruction
Instability
revision knee
prosthesis is used: hinged prosthesis components are in tight contact with
each other
Post-OP axis 6 Valgus