RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Musculoskeletal
MCHT Leading and
Education
ManagingIC3Your
Organisation
The Knee
Strategy Module – Presentation
Friday December 16th 2016
RCSI

Mr Adam Galbraith
LEARNING OBJECTIVES
1. Understand the anatomy of the
knee joint
2. Understand common knee
pathologies and their management
Learning objective 1

ANATOMY OF THE KNEE

JOINT
Basics
• Largest and most complicated joint in the
body
• Complex pivotal synovial hinge joint
• Knee – Genu
• Most commonly replaced joint
– Knee OA most common joint disease
• Most common arthroscopic procedure
Anatomy

• Connects the femur to the tibia

• Made up of medial and lateral condyles of femur

attaching to tibia condyles

• Gliding joint b/t the patella and patellar surface of the

femur

• Hinge joint b/t the femur and tibia

• Covered with a layer of hyaline cartilage

• Fibula is NOT part of the knee joint

Anatomy - Capsule

• Joint capsule attaches to the margins of

the articular surfaces and surrounds the
sides and posterior aspect of the joint

• The front the capsule is absent which

permits the synovial membrane to pouch
upward beneath the quadriceps tendon
creating the suprapatellar bursa
Anatomy - Ligaments

• Patellar Ligament (Tendon)

– Continuation of central portion of the quadriceps tendon
– From inferior patellar border to tibial tuberosity
Anatomy - Ligaments

• Medial Collateral Ligament

– Broad, flat band

– From medial femoral condyle to medial tibial shaft

– Provides stability against valgus stress

– It is firmly attached to medial meniscus

• NB MCL tears may also injure medial

meniscus
Anatomy - Ligaments

• Lateral Collateral Ligament

– Cordlike

– From lateral condyle of the

femur to fibular head

– Provides stability against varus

stress
 Anatomy - Ligaments
• Anterior Cruciate Ligament
– From anterior intercondylar area of
the tibia to the postero-medial
surface of lateral femoral condyle

– Slack when knee is flexed, taut when

knee is extended

– Prevents posterior displacement of

the femur on the tibia
Anatomy - Ligaments

• Posterior Cruciate Ligament

– Attaches to the posterior intercondylar
area of the tibia and the lateral
surface of the medial femoral condyle

– Slack when the knee is extended, taut

when the knee is flexed

– Prevents anterior displacement of the

femur on the tibia
Anatomy - Menisci
• Crescent shaped fibro cartilage

• Upper surfaces are concave and in contact with the

femoral condyles

• Lower surfaces are flat and in contact with the tibial

condyles

• Function: stability, lubrication, nutrition,

shock/energy absorption

• Medial meniscus is semicircular, attached to the

MCL, more commonly torn

• Lateral meniscus is more O shaped, NOT attached

to LCL
Anatomy - Muscles

• Quads • Hamstrings
Anatomy - Neurovascular

• Nerve Supply • Blood Supply

– Femoral, obturator, – The popliteal artery and
common peroneal, and its geniculate branches
tibial nerves (terminal form a rich anastomosis
branches of the sciatic around the knee joint
nerve)
Learning objective 2

COMMON PATHOLOGIES OF
THE KNEE AND THEIR
MANAGEMENT
Osteoarthritis

• OA knee most common joint

disease

• Revise pathogenesis:
– initial changes in articular cartilage 
fibrillation of cartilage vertical clefts
 exposure of subchondral bone 
eburnation
• Primary and Secondary OA
Osteoarthritis

• What are the 4 cardinal X Ray signs?

– A normal Knee
Osteoarthritis

• Loss of joint space

• Osteophyte

• Subchondral sclerosis

• Subchondral pseudocyst
Osteoarthritis

• Non operative
– Weight loss
– Exercise
– Physiotherapy
– Analgesia
• Operative
– Arthroplasty
• When patients have severe pain, nocturnal pain, pain at rest, and
severely restricted mobility
– Arthrodesis
• Rarely used
• Osteotomy
• Utilised to realign deformities and spread transmitted loads evenly
Rheumatoid Arthritis
• Chronic systemic disease of unknown aetiology

• Characterized by chronic symmetric inflammation of the joints

• Variable extra articular manifestations – eyes, skin, lungs etc

• F>M 4:1

• Genetic predisposition with HLA

• a/w low grade fever, loss of appetite, malaise & fatigue

Rheumatoid Arthritis

• Soft tissue swelling

• Juxta-articular osteopaenia

• Marginal erosions

• Joint space narrowing

• Deformity
– Hands are often affected
earliest
Rheumatoid Arthritis
• Medical Treatment:
– First Line Tx - NSAIDs
• Reduce stiffness and synovitis, improve mobility
– Second Line Tx - DMARDS
• Gold salts, penicillamine, immunosuppressants (methotrexate),
infliximab (anti tnf-α)
– Third Line Tx - Corticosteroids
• Systemic or Intra-articular in accessible joints

 Surgical Treatment
– Early in disease process before significant radiographic changes –
synovectomy (can be perfomed arthroscopically)
– Advanced disease
• Joint replacement (Arthroplasty)
Meniscal Injuries

• Apart from meniscal cysts, there are 3 common meniscal problems

– Congenital discoid meniscus
• Generally presents in childhood
– Longitudinal meniscus tears
• Occur in young adults, rarely in females
– Horizontal cleavage tears
• Occur in both sexes in middle age

• The periphery of each meniscus has a tenuous blood supply

• The central part of the meniscus is nourished by diffusion only

– It is thus incapable of repair
Meniscal Injuries
• Meniscal Cysts

• Relatively rare, but are distinctive

• More common in the lateral meniscus

– Often a history of local trauma
– Frequently an associated meniscal tear

• Cysts are in the joint line and very firm on palpation

• If symptomatic
– Treatment is by excision
Meniscal Injuries

• In the early stages of development the menisci are disc shaped

– Later, the central portion of the disc is resorbed, producing the normal semilunar
configuration
– In some people this process fails to occur
– The resulting solid meniscus tends to detach at its periphery

• If the meniscus is relatively stable

– Arthroscopic resection of the central portion
• Partial meniscectomy

• If meniscus is too unstable

– Arthroscopic total meniscectomy is often required
Meniscal Tears
O/E:
• Effusion

• Muscle wasting from long term

meniscal injury (pt won’t fully extend
so VMO becomes wasted)

• Localised palpable tenderness

• May have decreased extension, pain

on full flexion

• Positive McMurray/Apley grind test

Meniscal Tears

• Longitudinal tear is by far the most common types of meniscal injury

– Occurs in the young adult – traumatic
– Normally degenerative in elderly

• 3 factors are generally found to have been present

– The knee was weight bearing
– It was flexed
– It was twisted (i.e., subject to rotational stress)
• Most commonly the tear involves the mid-portion of the meniscus
– If the tear is extensive, the inner limb of the torn meniscus may
become displaced – Bucket Handle tear
– In others, further transverse tearing - Parrot Beak tear
Meniscal Tears
Arthroscopic resection of the torn portion
of the meniscus
Most popular method of treatment
Resect back to a stable rim

Open arthrotomy
Mainly reserved for failed arthroscopic resections

Meniscal repair
Reserved for peripheral tears in younger patients

Physio post op is essential - builds up

muscles
ACL Injury
• Most common ligament to be injured
• Most frequent cause of acute haemarthrosis
• It can be torn in isolation
– Often, other structures injured simultaneously
• Mechanism of Injury
– External rotation of the tibia on the femur combined with an abduction force
• Pt gives a history of significant injury
– Often with the sensation of something giving within the knee or an audible
“pop”
– Invariably followed by a rapidly forming haemarthrosis
• Some patients present late
– Complain of feelings of instability
– Incidents of giving way followed by effusion
– Can be difficult to differentiate from a meniscal tear
ACL Injury

• Anterior Drawer Test • Lachmanns Test

ACL Injury

• Non operative • Operative

– Knee Supports – Surgery is reserved for
patients who during normal
• Basic
activities have symptoms of
• Hinged instability
• Stabilised – Common reconstructive
– Intensive Physiotherapy procedures use either part of
the patellar ligament or
woven synthetic implants
PCL Injury

• Much less common than ACL injury

– Often found combined with other ligamentous injuries

• Mechanism of Injury
– Fall on the flexed knee
– Dashboard impaction during an RTA

• May be overlooked unless the possibility of its occurrence is kept in mind

and a careful examination is performed
• When the knee is flexed, the tibia usually sags backwards under the femur
• Comparison with the opposite side is essential
PCL Injury

• In acute cases, conservative treatment is often advocated

– Intensive quadriceps exercises can produce good results

• Persisting instability can lead to severe and rapidly progressive OA

– If conservative measures fail, surgical ligament reconstruction may reduce the risk of
serious complication

• Positive sign on the Posterior draw test

• Instability of the joint
• Associated with the feeling of the knee giving way
Collateral Ligament Injury

• Commonly injured

• MCL is more frequently affected

• Requires significant force

– Sporting tackle
– Blow to the side of the leg from a motor vehicle

• In a number of cases there are associated fractures of

the tibial plateau
Collateral Ligament Injury

 Apply RICE
 Rest from training
 Wear a hinged knee brace to support the joint in severe
injuries
 Wear a heat retainer after the acute phase
 Apply a support bandage or plaster cast.
 Aspirate the joint if effusion present
 Apply sports massage techniques
 Physio
 US/ laser therapy
 Surgery
Retropatellar Pain Syndrome

• Characterised by ill-localised patellar pain

– No specific features apart from being made worse by prolonged sitting or by walking
on slopes or stairs
– Pain is usually not severe but may sometimes limit activities
– Sometimes a small joint effusion – knee may give way
– Common in adolescent and young females
– Generally self limiting

• No clear cut pathological lesion

– Deep layers of the articular cartilage of the patella may degenerate (Chondromalacia
patellae)
Retropatellar Pain Syndrome

• Investigation
– X-Rays which should include a skyline (tangental) view
• May reveal maltracking of the patella

• Treatment
– General advice is given to avoid activities which are known to
aggravate the condition

– Quadriceps building exercises

Osgood-Schlatter’s Disease

• Common problem in the young adolescent

• It is a traction apophysitis
– Can be bilateral

• Causes mild pain which is worse after

exercise

• Typically, the tibial tubercle is tender and

prominent
– Knee movements are unaffected
Osgood-Schlatter’s Disease

• A lateral radiograph shows displacement or

fragmentation of the apophysis

• Treatment is generally symptomatic as the

condition is self-limiting

• Restriction of activity may be sufficient

– In refractory cases, 6 weeks immobilisation in a
plaster cast may be required
Osteochondritis Dessicans

• Condition in which a small fragment of bone just deep to

the articular surface is rendered avascular
– Along with the healthy cartilage capping it, it becomes detached
from the healthy structures
– Can form a loose body

• Aetiology uncertain
– Contact between the femoral
condyles and tibial spines or
ACL may be significant
Osteochondritis Dessicans

• 70% of defects involve the lateral aspect of the medial

femoral condyle
– May be bilateral

• Initially it is symptom free

– Later it may cause mild pain in the joint and an effusion

• Loose body may cause locking of the joint

Osteochondritis Dessicans

• Diagnosis
– Often confirmed by routine x-rays of the knee
• Specialised tunnel projections – show intercondylar area

– Arthroscopic assessment
• Helpful in deciding whether the fragment is becoming detached and likely to form a loose
body

• Treatment
– Fragment remains in situ
• Observation with serial x-rays
– Mobile fragment
• Area may be drilled – promotes healing
• Defect may be pinned back / loose bodies removed
Orthopaedic Interventions

• Total Knee Replacement

• Femoral and Tibial components

– Polyethylene liner
Orthopaedic Interventions
• Unicondylar Knee
Replacement
– Knee is divided into medial,
lateral, and patellofemoral
– 10-30% of patient have wear
only in one compartment
– Pros: smaller incision, easier
rehab, shorter hospital stay, less
blood loss, lower infection risk
– Cons: less reliable long term
– NB Patellofemoral Replacement
CLINICAL VIGNETTE
Clinical Vignette

• A 62 year old female presents to your General Practice

complaining of right anterior knee pain for the past 18
months. The knee pain is now limiting her mobility as
she struggles to walk more that 300 meters without pain
and finds descending stairs difficult. The pain is no
longer responsive to Paracetamol or NSAIDS, and it
keeps her awake at night. She denies any history of
trauma or previous knee problems.
Clinical Vignette

• Crepitus
• Painful and decreased range of motion of the right knee
with a flexion deformity
• BMI 34Kg/m2
Clinical Vignette

• What is your differential diagnosis?

• Why is knee OA likely?
• Why are the other diagnoses unlikely?
• What investigations would you do?
• What are the management options?
 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Musculoskeletal
MCHT Leading and
Education
ManagingIC3Your
Organisation
The Knee
Strategy Module – Presentation
Friday December 16th 2016
RCSI

Mr Adam Galbraith