Internal

Derangements of
knee and its
examination
Dr. Rajiv Kumar
P.G. D.orth
Santosh medical college &

Internal derangements of the

knee (IDK)
It is a term used to cover a group of
disorders involving disruption of the
normal functioning of the ligaments
or cartilages (menisci) of the knee
joint.

ANATOMY OF KNEE JOINT

Bones &
Articulations

Largest joint in the

body
Synovial hinge type of
a joint
Mainly articulation of
four bones ;femur,
tibia, patella,
fibula
Each articulation
covered with hyaline

LIGAMENTS
Dense structures
of connective
tissue that fasten
bone to bone &
stabilise the knee.
Inside the knee
are two major
ligamentsanterior &
posterior cruciate
ligaments

 Two other ligaments are

located outside the knee
Medial & Lateral collateral
ligaments. They act to
stabilise knee sideways
motion.
The patellar tendon connects
lower part of patella with
upper part of tibia. Part of
this tendon is used in
Reconstructing a torn ACL

MENISCI
Two menisci
are in each knee.

Act as shock
absorbers & also
help in spreading
weight .
A meniscus is
frequently torn at
the same time as
ACL tears during
injury.

Classification

The following disorders may be met with:Sprain or tear of the medial collateral ligament.
Sprain or tear of the lateral collateral ligament.
Partial or complete rupture of the anterior cruciate ligament.
Rupture of the posterior cruciate ligament.
Tear of the medial semilunar cartilage. This may take the
form of a longitudinal spilt (bucket handle tear), or an
anterior or posterior horn tear.
Tear of the lateral semilunar cartilage. The same variations
occur as with a medial cartilage tear.
Tear of a degenerate meniscus.
Cyst of a semilunar cartilage, usually the lateral.
THE COMMONEST DERANGEMENT IS MEDIAL COLLATERAL
LIGAMENT INJURY FOLLOWED BY MEDIAL MENISCUS INJURY
AND ACL

Aetiology
Physical trauma is the cause of the vast
majority of IDKs.
The majority of acute knee injuries result
from a valgus and/or twisting strain. Most
commonly, they involve the medial joint
structures and the anterior cruciate
ligament.
The type of physical trauma causing IDK
may be a sports injury, a road traffic
accident or an occupational stress; by far
the most common at the present time is a

 The most frequent cause of damage to

the medial collateral ligament is forced
valgus injury to the knee
Lateral collateral ligament injuries are
much less common, as varus stress to the
knee occurs much less frequently than
valgus stress.
Anterior cruciate ligament injury occurs
from forced valgus stress to the fully
extended knee.
Posterior cruciate ligament injury is liable
to occur in motor car accidents caused by

 Meniscus tears occur when

substantial rotational stresses are
applied to the flexed knee. They are
particularly common in footballers,
when the player is tackled from the
side; they are also liable to occur in
other sports such as hockey, tennis,
badminton.

MEDIAL COLLATERAL
LIGAMENT

Anatomy:
MCL is composed of superficial & deep portions
superficial MCL
anatomically this is the middle layer of the
Medial compartment
proximal attachment: posterior aspect of medial
femoral condyle.
distal attachment: metaphyseal region of the
tibia, upto 4-5 cm distal to the joint, lying under
the pes anserinus

function:
provides primary restraint to valgus
stress at the knee providing from > 6070% of restraining force depending on
knee flexion angle:
at 25 of flexion, the MCL provides 78%
of the support to valgus stress;
at 5 of flexion, it contributes 57% of the
support against valgus stress;

superficial ligament can be divided

into
anterior & posterior portions;
anterior fibers of superficial portion
of
ligament appear to tighten with knee
flexion
of 70 to 105 deg;
posterior fibers form the posterior

Deep MCL

anatomically this is the third (deep) layer of the

medial compartment which in many cases will
beseparated from the superficial MCL (layer II) by
a bursa (which allows sliding of the tissues during
flexion)

divided into meniscofemoral and meniscotibial

ligaments

inserts directly into edge of tibial plateau &

meniscus

firmly attaches to the meniscus but does not

provide significant resistance to valgus force

Examination Findings:
valgus stress test
clinical findings may not match complete injury;

it is helpful to anchor the thigh on the table with

the knee and leg off the edge of the table;

opening of 5-8 mm compared to opposite knee

may indicate complete tear;

determine the point of maximal tenderness to

determine whether the tear has occurred
proximally, mid-substance, or distally;

instability in slight flexion:

anterior portion of the medial capsule is
primary stabilizer at 30 deg of flexion;
hence at 30 flexion, testing is specific for
just MCL;

instability in extension:
posterior portion of the MCL, posterior
oblique ligament, ACL, medial portion
of posterior capsule & possibly PCL;

 location of tears:
- femoral tear:

- mid substance tear:

- tibial tear:

INVESIGATIONS

- X-ray:
- MRI:

combined ACL/ MCL

injuries
with concomitant MCL and ACL tears,
most surgeons now recommend ACL
reconstruction after the valgus
stability has returned
the one exception might be the MCL
tear arising from the tibial insertion

Lateral collateral ligament

Discussion
lateral collateral ligament is primary restraint to
varus
angulation
LCL also acts to resist internal rotation forces
cutting of LCL in combination with either anterior or
PCL results in large increase in varus opening

varus stress test

testing with extension:
LCL resists approximately 55 % of applied load at full
extension
cruciate ligaments (primarily ACL) resist approx 25% of
moment at
full extension
significant instability in full extension indicates
complete LCL tear as
well as a tear of either the ACL or PCL ligament
note that LCL instability in extension which occurs with

testing with 30 deg flexion:

role of LCL increases with joint flexion, as posterolateral
structures
become lax
with joint flexion,resistance by ACL decreases, but large
forces are
found in PCL at 90 degrees of flexion
LCL is primary restraint to varus stress at 5* &
25*Flexion
lateral capsular structure provide secondary support
iliotibial band & popliteus muscles have dynamic

Surgical Reconstruction:
allograft reconstruction:
With chronic posterolateral injury, Achilles tendon
allograft may be indicated
At the level of Gerdy's tubercle, a bone tunnel is
created in the posterolateral tibia, just medial to
the fibular head
Attachment of the IT band to the intermuscular
septum may have to be freed for optimal
exposure

FUNCTIONAL ANATOMY OF
ACL

The ACL is a broad ligament joining the

anterior tibial plateau to the posterior
intercondylor notch.
The tibial attachment is to a facet, in
front of & lateral to anterior tibial spine.
Femoral attachment is high on the
posterior aspect of the lateral wall of the
intercondylar notch.
It is composed of multiple non-parellel
fibres which though not anatomically
separate, act as three distinct bundles i.e.

FUNCTIONS
The biomechanical function of the ACL is
complex for it provides both mechanical
stability & proprioceptive feedback to the
knee.
In its stabilising role it has four main
functions;
1.Restrains anterior
translation of tibia.
2.Prevents
hyperextention of knee.
3.Acts
as a secondary stabiliser to valgus stress,
reinforcing medial collateral ligament.

ACL deficiency causes failure of this screwhome

mechanism,resulting in subluxation of tibia on
the femur.

This critical function in the range of 0-30* is

important for

 T he ligament is surrounded by synovium,thus

making it extra synovial.

Blood supply
primarily from the middle genicular Artery which
pierces the posterior capsule & enters the
intercondylar notch near femoral attachment.
Additional supply comes from retropatellar pad
of fat via the inferior medial & lateral geniculate
arteries.
NERVE SUPPLY: Posterior articular nerve

 Rupture of ACL causes significant short

term & long term disability.
With each episode of instability there
is subluxation of tibia on the femur,
causing stretching of the enveloping
ligaments & abnormal shear stress on
the menisci & on the articular
cartilage.
Delay in the diagnosis & treatment
gives rise to increased intrarticular

The long term outlook for an ACL

deficient knee is for the development of
significant osteoarthrosis.
CAUSES OF ACL RUPTURE
1.Most common cause of ACL rupture is

traumatic force applied to the knee in a

twisting moment. This can occur with
direct or indirect force.
2.Patients with narrow
intercondylar notch are more prone to

3.Patients with genu recurvatum tend to

be more likely to rupture their ACL &
are more difficult to treat.
4.Patients with generalised ligamentous
disorder.

5.Familial predisposition has been found

to play a role in some patients
especially those who sustain bilateral
ACL tears.

Classical history
Begins with a non contact deceleration,
jumping or cutting action.
Other mechanisms of injury include external
forces applied to the knee.
The patient often describes the knee as having
been hyperextended or popping out of the joint
& then reducing. A pop is being frequently
heard or felt. The patient usually has fallen to
the ground & is not immediately able to get up.
Resumption of activity is not possible & walking
is often difficult. Within a few hours knee swells
& aspiration of joint reveals haemarthosis. In
this scenario ,the likelihood of ACL injury is

Examination
ANTERIOR DRAWER TEST
With the knee flexed to 90*, verification of relaxation of
hamstrings is confirmed. With foot stabilised & in neutral
rotation, a firm but gentle grip on the proximal tibia is
achieved.

 An anterior force is applied to the proximal tibia

with a gentle to & fro motion to assess for
increased translation compared to contralateral
knee. 5mm is the upper limit of anterior tibial
displacement normally.

 Drawer sign is minimal in isolated ACL

rupture. Abnormal displacement >5mm is
permitted by loss of restraint by ACL &
more so when associated with
insufficiency of medial CL or capsular
ligament.
When an intact PCL is rendered very taut
by forcible internal rotation of tibia, it
stabilises the knee to the extent that the
anterior drawer sign is negated.

LACHMANS TEST
One hand secures
and stabilises the
distal femur while
the other hand
grasps the
proximal tibia.

A gentle anterior
translation force is
applied to the
proximal tibia.

LACHMANS TEST CONTD

Examiner assesses
for a firm/solid or
soft endpoint.

Stabilisation of right
knee during an
examination under
anaesthesia.

 Application of anterior tibial translation force

with significant ant. translation of the tibia on
the femur in an ACL deficient knee.
When veiwed from side,
a silhoutte of the inferior
pole of patella,
patellar tendon &
proximal tibia shows slight
concavity.
Disruption of ACL &
anterior translation of tibia
obliterates the patellar
tendon slope.

PIVOT SHIFT TEST

Patient rotated 20* from supine towards the
unaffected side. With slight distal traction on
the leg,a valgus & internal rotation force is
applied to the extended knee.

 With maintainance of force noted

above,the knee is flexed past 30*

 Pivot shift in an ACL deficient

knee,in the initial stages of knee
flexion,the tibia will be
anterolaterally subluxed on the
distal femur with application of
valgus & internal rotation at the
knee.

 With further flexion of knee(past 30*) the

illiotibial band goes from an extendor to
flexor of knee & tibial anterolateral
subluxation reduces back in place.

 Isolated tear produces only small

subluxation, greater subluxation occurs
when lateral capsular complex or
semimembranosus corner also is
deficient.
DISADVANTAGES:
Severe valgus instability may make this
test difficult to do because of lack of
medial support.
FLEXION ROTATION DRAWER
TEST
Combines anterior drawer & pivot shift

ARTHOSCOPY:Acute complete tear most

often found through the midportion &
may appear ragged.Less often it is torn at
its either end.

Roentgenographic studies:
Plain roen.often are normal, however,a
tibial eminence fracture indicates an
avulsion of the tibial attachment of
ACL.MRI is the most helpful.

MRI FINDINGS:

1.PRIMARY SIGNS:
Nonvisualisation
Disruption of the substance of ACL by increased
abnormal signal intensity
Abrupt angulation
Wavy appearance
Abnormal ACL axis.

2.SECONDARY SIGNS:
Segonds fracture
osteochondral fracture
Anterior translation of tibia
Pivot shift
Bone bruises.

LEFT-Normal ACL in axial plane;

RIGHT: Non-visualisation as primary sign of
ACL tear with ill-defined edema &
haemorhage in the usual location of the ACL
in the I/C NOTCH.

ACL tear with nonlinearity of ligament;

mild angulated ACL

segonds fracture in a
patient with ACL tear.

 Anterior
translation of
tibia as a
secondary sign
of ACL tear.
Tangential line to
the posterior
margin of tibia
passes through
the posterior
horn of lateral
Meniscus
(uncovered
meniscal sign).
In normal knee,
this line passes

 Before any surgical Rx, patient is sent to

physical therapy.
Resolution of inflammation & return of
full motion reduce the incidence of
postoperative stiffness
It usually takes 2 to 3 weeks from the
time of injury to achieve full range of
motion.
It is also recommended that some

Surgical options
Repair of ACL either isolated or with
augmentation.

Reconstruction with either autograft,

allograft or syntheticsp
Primary repair of the ACL is no longer
recommended because repaired ACL
have generally been shown to fall
overtime.
The torn ACL is generally replaced by a

POSTERIOR CRUCIATE
LIGAMENT:
ANATOMY

Intra-articular but extrasynovial, static

stabiliser of knee:
composed of two major parts:Large anterior
part that forms the bulk of the ligament & a
smaller portion that runs obliquely to the back
of tibia.
PCL is attached proximally to the posterior
part of the latral surface of the medial
condyle.The tibial attachment is to a

Origin & insertion sites of posterior

cruciate ligament:

Arthroscopic view of PCL:

Biomechanics:

Progressive tightening of the PCL occurs

during internal rotation of tibia with the
knee in either flexion or full extension.
Also in full extension the PCL allows only
minimal abduction or adduction widening of
the knee despite complete removal of
accessory supports;the extensor
retinaculum, capsular ligaments, collateral
ligaments & posterior capsule.
This fact emphasis the importance of the
PCL as the basic stabiliser of the knee, while

Functions
provides restraint against hyperextension,
against posterior displacement of tibia in
flexed knee,
internal rotation of the tibia &
valgus/varus angulation-particularly in
extended knee.

ACUTE TEAR: Requires much more force than to tear

ACL.

Following ways:
1.Severe rotational injury; an external rotation-valgus
injury or an internal rotation-varus injury produces
tear of PCL assoc. with disruption of MCL or LCL.The
PCL is interupted at its midportion or at its femoral
attachment.
2.Hyperextension injury: Tibial attachment is avulsed
usually
3.Direct trauma to upper tibia while the knee is flexedDashboard injury.

CLINICAL PICTURE:
History of severe trauma is elicited.
Degree of both immediate pain & inability to
bear weight on the injured knee is highly
variable.
These are more pronounced when capsule is
intact & haemarthrosis is confined within the
joint.
They may be minimal when the posterior capsule
is disrupted & blood escapes from the joint.

 Objective findings are:

tenderness in the popliteal fossa;
swelling in allmost all cases.
Posterior drawer sign in allmost 60%
of cases.

POSTERIOR DRAWER TEST

With knee flexed to approx. 90*, verification of
complete relaxation of hamstrings is confirmed
by palpation .

 With foot in neutral

rotation & stabilised,
a firm but gentle
posterior translation
force is applied to
proximal tibia.

Initial starting point

for a posterior drawer
test(foot in NR, knee
flexed to 90*)

 Application of
posterior
translation force
results in posterior
subluxation of tibia
on the femur in a
patient with PCL
deficient knee.

TIBIAL BACK DROP TEST

In this test, the examiner compares the prominence of the
proximal tibia
to the femoral condyles with the knee flexed to 80*.
In a PCL deficient knee, the knee will be posteriorly
subluxed due to gravity.

In a normal knee at 80* the tibial plateau

is located approximately 1cm anterior to
the femoral condyles

TIBIAL BACK DROP

TEST IN A PCL
DEFICIENT LEFT KNEE

NORMAL
CONTRALATERAL
RIGHT KNEE.

QUADRICEPS ACTIVE TEST:

It is performed
with the knee
flexed to 80deg &
in neutral
rotation.Its
starting point is in
effect the tibial
drop back test.

 From its initial

relaxed position, the
patient is asked, to
contract Quadriceps
muscle (straighten
out his leg without
extending his knee)
while examiner
applies counter
pressure against the
ankle.

Quadriceps pulls anteriorly

through the tibial tubercle to
reduce any posterior
translation in the knee.

Reduction of a posteriorly
subluxed tibia with
Quadriceps contration in a PCL
deficient knee.

Contraction of the quadriceps

muscle in a knee with a PCL
deficiency results in an anterior
shift of >2mm.

ROENGENOGRAPHIC FINDINGS:
Plain radiographs usually normal.
Stress radiography assists in the
diagnosis of PCL injuries.
Increased posterior translation of 8mm or
more in stress roeng.is indication of
complete rupture.
A contrast arthogram may reveal
evidence of ligament disruption.
Arthroscopic evaluation should be done
to assess the damage to both the
cruciates & to define additional lesions.

 MRI studies are more reliable for

diagnosis of PCL tears than ACL
tears.

RECONSTRUCTION OF PCL:Can be done by open or

Arthroscopic technique;arthroscopic technique is prefered.

Various grafts used are :

(1).Patellar tendon graft.
(2).Bone-patellar tendon-bone
graft.
(3).Tendo-achillis bone
graft.
(4).Illiotibial band.
(5).Medial head
of gastrocnemius tendon.
(6).Hamstring tendon.

MENISCUS
INJURY

Anatomy
The menisci are C-shaped or semicircular
fibrocartilaginous structures with bony
attachment at anterior and posterior tibial
plateau. The medial meniscus is C-shaped,
with a posterior horn larger than the anterior
horn in the anteroposterior dimension.
The capsular attachment of medial meniscus
on the tibial side is referred to as the
coronary ligament. A thickening of the
capsular attachment in the midportion spans
from the tibia to femur and is referred to as
the deep medial collateral ligament.

 The lateral meniscus is also anchored

anteriorly and posteriorly through
bony attachments and has an almost
semicircular configuration. It covers a
larger portion of the tibial articular
surface than does medial meniscus

 The fibrocartilaginous structure of the

meniscus has a varied architecture of
coarse collagen bundles.
At birth the entire meniscus is vascular.
By age 9 months, the inner one-third
has become avascular. This decrease in
vascularity continues by age 10 years,
when the meniscus closely resembles
the adult meniscus.

 In adults, only 10 to 25% of the lateral

meniscus and 10 to 30% of the medial
meniscus is vascular. This vascularity
arises from superior and inferior
branches of the medial and lateral
genicular arteries, which form a
perimeniscal capillary plexus.
Because of the avascular nature of the
inner two-thirds of the meniscus, cell
nutrition is believed to occur mainly
through diffusion or mechanical
pumping.

 The classification of meniscal tears

provides a description of pathoanatomy.
The types of meniscus tears are:
Longitudinal tears that may take the
shape of a bucket handle if displaced
Radial tears
Parrot-beak or oblique flap tears
Horizontal tears and
Complex tears that combine variants of
the above.

History
Most meniscal injuries can be
diagnosed by obtaining a detailed
history.

Mechanism of injury

Meniscus tears are sometimes related to

trauma;but significant trauma is not
necessary.
A sudden twist or repeated squatting can tear
the meniscus.
Meniscus tears typically occur as a result of
twisting or change of position of the weightbearing knee in varying degrees of flexion or
extension.

Pain from meniscus injuries is commonly

intermittent; usually the result of synovitis or
abnormal motion of the unstable meniscus
fragment & is localized to the joint line.
Mechanical complaints: Descriptions by patients
are often nonspecific but include reports of
clicking, catching, locking, pinching or a sensation
of giving way.
Swelling usually occurs as a delayed symptom or
may not occur at all. Immediate swelling indicates
a tear in the peripheral vascular aspect.
Degenerative tears often manifest with recurrent
effusions due to synovitis.

Physical findings
Joint line tenderness
Joint line tenderness is an accurate clinical
sign. This finding indicates injury in 77-86%
of patients with meniscus tears. Despite the
high predictive value, operative findings
occasionally differ from the preoperative
assessment.
The examiner must differentiate collateral
ligament tenderness that may extend further
toward the ligament attachment sites above
and below the joint line.

 Effusion
Effusion occurs in approximately 50% of the
patients presenting with a meniscus tear.
The presence of an effusion is suggestive of a
peripheral tear in the vascular or red zone
(especially when acute),an associated intraarticular injury, or synovitis.

Range of motion
A mechanical block to motion or frank locking
can occur with displaced tears.
Restricted motion caused by pain or swelling
is also common.

Provocative maneuvers
These techniques cause impingement by
creating compression or shearing forces
on the torn meniscus between the
femoral and tibial surfaces.

The McMurray test:

This maneuver usually elicits pain or a
reproducible click in the presence of a
meniscal tear.
The medial meniscus is evaluated by
extending the fully flexed knee with the
foot/tibia internally rotated while a varus
stress is applied.
The lateral meniscus is evaluated by
extending the knee from the fully flexed
position, with the foot/tibia externally
rotated while a valgus stress is applied to
the knee.

The Steinmann test:

Tibial rotation is performed with the patient
seated and the knee flexed 90*.Asymmetric
pain is created with external (medial
meniscus) or internal (lateral meniscus)
rotation.

The Apley test:

This maneuver is performed with the patient
prone and the knee flexed 90*. An axial load
is applied through the heel as the lower leg is
internally and externally rotated. This
grinding maneuver is suggestive of meniscal
pathology if pain is elicited at the medial or

 Differential diagonosis

Anterior Cruciate Ligament Injury

Synovial Plica Irritation
Patellofemoral Joint Syndromes
Iliotibial Band Syndrome
Knee Osteochondritis Dissecans
Posterior Cruciate Ligament Injury
Lateral Collateral Knee Ligament Injury
Medial Collateral Knee Ligament Injury
Articular cartilage pathology including arthritis
Bipartite patella
Chondromalaciae patellae
Recurrent dislocation of patella.
Patella alta/Patella baja/pseudo patella baja
Some avulsion fracture like Segond fracture and reverse segond fracture
Biceps femoris avulsion fracture
Patellar tendon avulsion fracture
Tibial plateau fracture
Knee dislocation.

Imaging Studies
Plain radiography: An AP weight-bearing view,
PA 45* flexed view, lateral view and Merchant
patellar view should be obtained to rule out
degenerative joint changes (arthritis) or
fractures
Arthrography: Historically, arthrography was
the standard imaging study for meniscal tears
but it has been replaced now by MRI.
MRI: This is the standard imaging study for
imaging meniscus pathology and all intraarticular disorders.

Treatme
nt

 Acute Phase
Rehabilitation Program
Physical Therapy

 A home physical therapy program or simple rest with

activity modification, Ice and NSAIDs is the
nonoperative management of possible meniscus tears.
The physical therapy program goals are to minimize the
effusion, normalize gait, normalize pain-free range of
motion, prevent muscular atrophy, maintain
proprioception and maintain cardiovascular fitness.
Choosing this course of treatment must include
consideration of the patient's age, activity level,
duration of symptoms, type of meniscus tear, and
associated injuries such as ligamentous pathology

A trial of conservative treatment should be attempted

in all but the most severe cases, such as a locked knee
secondary to a displaced bucket-handle tear

Medical
Issues/Complications
The main complication at this stage of
treatment is the absence of healing and
failure of symptoms to resolve.
The natural history of a short (<1 cm),
vascular, longitudinal tear is often one of
healing or resolution of symptoms.
Stable tears with minimal displacement,
degenerative tears, or partial-thickness
tears may become asymptomatic with
nonoperative management.

 Most meniscal tears do not heal without

intervention.
If conservative treatment does not allow
the patient to resume desired activities,
his or her occupation, or a 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

Surgical Intervention
Indications: Symptoms persist.
If the patient cannot risk the delay of a potentially
unsuccessful period of observation.
In cases of a locked knee.
Principle of meniscus surgery is to save the meniscus.
Tears with a high probability of healing with surgical
intervention are repaired.
Most tears are not repairable and resection must be restricted
to only the dysfunctional portions, preserving as much normal
meniscus as possible.

 Surgical options include partial meniscectomy

or meniscus repair (and in cases of previous
total or subtotal meniscectomy, meniscus
transplantation).

Arthroscopy, a minimally invasive outpatient

procedure with lower morbidity, improved
visualization, faster rehabilitation, and better
outcomes than open meniscal surgery, is now
the standard of care.

 Partial meniscectomy is the treatment of choice

for tears in the avascular portion of the
meniscus or complex tears that are not
amenable to repair.

Meniscus repair is recommended for tears that

occur in the vascular region (red zone or redwhite zone), are longer than 1 cm, involve
greater than 50% of the meniscal thickness,
and are unstable to arthroscopic probing.

Human allograft meniscal

transplantation is a relatively new
procedure but is being performed
increasingly frequently.
Specific indications and long-term
results have not yet been clearly
established.
Meniscus transplantation requires
further investigation to assess its
efficacy in restoring normal
meniscus function and preventing

 Recovery Phase
Rehabilitation Program
Physical Therapy
Physical therapy during recoveryis
directed towardthe same goals as those
in the acute phase.
For partial meniscectomy, patients may
return to low-impact or nonimpact
workouts such as stationary cycling or
straight-leg raising on the first
postoperative day and may advance
rapidly to preoperative activities

 When a meniscus repair is

performed, the rehabilitation is
typically more intensive.
Three main issues are considered in
the rehabilitation of meniscus
repairs: knee motion, weight bearing,
and return to sports.
A common protocol is avoidance of
weight bearing for 4-6 weeks, with
full motion encouraged.

 Complications
Reported complication rates for arthroscopic
meniscectomy range from 0.5-1.7% and these can
occur intraoperatively or postoperatively.

Intraoperative complications include anesthetic

problems, articular cartilage damage, vessel or
nerve injury or instrument failure.

 Postoperative complicationsinclude anesthetic

concerns, thrombophlebitis, hemarthrosis,
infection, stiffness, persistent pain, effusion or
synovitis.

Reported complication rates for meniscus

repairs range from 1-30%.

The list of complications is the same as that for

meniscectomies, with a greater concern for
neurovascular injury. Additionally, failure to heal
or meniscal reinjury can occur.

Osteochondritis dissecans
In this subchondral bone become
necrotic and degenerative changex
in the cartilage
During the course of disease,
necrotic bone and cartilage
separates from the adjacent bone
and come down into the joint.
Most common source of loose body
in the joint like: Osteophyte

Etiology

Endocrine
Familial predisposition
Accessory centre of ossification
Repeated microtrauma
Interruption of inerosseus blood
supply
Child with open physis.

Clinical Features
Pain
Catching and popping
Mimic to meniscal derangement of
the knee joint.
Wilson sign positive
Investigations: X Ray, CT amd MRI

Synovial plicae
Knee is separated into the
compartments by the synovial
membrane
Incomplate resorption of synovial
membrane during second trimester
of pregnancy
Till adult life, only subsynovial fold is
left (Plicae)
Can be:- Suprapatellat, Infrapatellar,
Mediopatellar, Lateropatellar.

Etiology
Any condition producing Chronic
irritation like trauma or scarring and
any post operative condition.
Clinical features: Popping , catching of knee joint.
Best diasgnosis by arthroscopy.

Chondromalaciae patellae
Degenerative changes in the
articular surface of patella.
Synonyms with Patello femoral pain.
There is decrease in sulfated
polysaccharide in the ground
substance and collagen fibre.
Can be demonstrated by loss of
basophillia on hematoxyllin and eosin
preparation.

Grades
1. Minimal articular changes,
localised softening, blunt instrument
shink the cartilage.
2. Changes includes fibrillation ,
fissuring and irregular surface.
3. Fibrillation & fissuring till
sunchondral bone.
4. Erosion of subchondral bone and
disapperance of articular cartilage.

Clinical features
Pain in sitting for a long time. (Movie
sign/Theatre sign)
Articular cartilgae debris settles in
the joint leading to chemical irritation
causing swelling and pain.
Investigations: X Ray, MRI, CT scan

Bipartite patella

Usually asymptomatic
Incidental finding
On AP view.
Type 1- 5% , in inferior pole of
patella, associated with sinding
larsen johanson syndrome.
Type 2- 20% , involves entire lateral
border of patella.
Type 3- 75% , supero lateral portion
of patella (Most common)

Investigation
X Ray should be taken in squatting
or weight bearing position
CT scan and MRI.