Knee joint Anatomy, clinical examination, imaging, pathology Anatomy- skeleton rozkydal_koleno_back rozkydal_koleno_front rozkydal_koleno_iso Complicated osseous sctructure- soft tissue for stability is needed Koleno medial Medial side KOleno lateral Lateral side Cruciate ligaments Koleno ACL Koleno PCL Menisci Koleno menisky KOleno zepředu Muscles Stability of the knee- muscles http://www.aafp.org/afp/1999/1201/afp19991201p2599-f2.jpg Anatomy- bursae http://www.thesoccerdoc.com/images/kKnee_bursitis_image.jpg Entezo- Baker cysta1 Anatomy- vessels http://classconnection.s3.amazonaws.com/694/flashcards/597694/jpg/knee_joint31312153908215.jpg Anatomy- nerves http://classconnection.s3.amazonaws.com/14/flashcards/1581014/jpg/ess_knee1340493831911.jpg Biomechanics Level Movement Sagital flexion/extension - rolling - gliding Transversal ext/ int roration Frontal adduction/abduction Koleno průřez Clinical examination •skin •swelling •alignment •deformity •contracture •active and passive movement •stability •meniscus manevuers •femoropatelar joint http://t0.gstatic.com/images?q=tbn:ANd9GcR2G3ITCm6X0K0PIL4UcpIIod-W3k939_XOyQpSxlv3pHDYANiD Swelling in the knee region •Effusion •Synovitis •Cysts, ganglion •Tumors •Haematoma • • H:\Výuka\kloub\3014[1].jpg Alignment of lower extremity OO- Mikulič M-osa DK M- osa DK 2 Mikulicz line Mechanical Anatomical Deformity of the knee joint OO-deformity kolena Genu varum • M.Blount • rachitis • posttraumatic • O.A. Genu valgum • rachitis • posttraumatic • R.A. • O.A. Osteo- Blount1 M. Blount Disorder of the growth plate of proximal tibia Deformity of the knee joint Genu recurvatum • congenital • aplasia of ext. apparatus • laxity of mesenchyme Genu flectum • cerebral palsy • other neurological disorders • O.A., R.A, post infection OO-deformity kolena OO- genu recurvatum Genu recurvatum congenitum Position of the knee joint •Semiflexion –antalgic –extension blockage •Rupture of meniscus •Loose body •Entrapement of synovial plica http://ars.els-cdn.com/content/image/1-s2.0-S1360859208001277-gr1.jpg Flexion contracture in cerebral plasy •Contracture of hamstrings (m. semitendinosus, m. semimembranosus, m. gracilis, m. biceps femoris) •Patella alta • – – http://www.radiologytutorials.com/getimage.cgi?i=bilder/2/310-1&r=1400 Movement in the knee joint H:\Výuka\Nová složka\koleno.jpg S extension - 0 - flexion S 0 - 0 - 140 • active, pasive http://t3.gstatic.com/images?q=tbn:ANd9GcSixC6b2C-GmHizZE4uxSbmn83k42ubcy14ur9Mr-C_v-BLjFCR Test for stability http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-1750718-1909230-2020095tn.jpg Valgus stress test (LCM) http://www.sportsdoc.umn.edu/clinical_folder/knee_folder/knee_exam/mlinstabvarus2-2.jpg Varus stress test (LCL) S2400094 Assesment Cruciate ligaments http://www.society-of-sports-therapists.org/picts/knee%20examination.JPG http://ars.els-cdn.com/content/image/1-s2.0-S0001209206609368-gr3.jpg http://t3.gstatic.com/images?q=tbn:ANd9GcTUIGw3BfMKEBHffIOG0ah-tBFbHDVmIIdL5lkv7Zk7sfAVMzgc0g Ant. drawer sign , post. drawer sign normal ant post Lachmann test S2400094 Meniscus manoeuvres http://www.mikereinold.com/wp-content/uploads/blogger/19-image5.png McMurray test http://openi.nlm.nih.gov/imgs/rescaled512/3213012_1758-2555-3-25-3.png C:\Users\Lukas\Desktop\X\steinmann.png Steinmann test Meniscus manouevres http://t2.gstatic.com/images?q=tbn:ANd9GcTnGKP06_ahMBJs9Ce_XLegShbsF31_58m1eggDs4p1mMNxViK-ssk6QQ http://www.netterimages.com/images/vpv/000/000/011/11066-0550x0475.jpg Appley test http://t2.gstatic.com/images?q=tbn:ANd9GcRsGZwaklPyXvBg2CkFkdDvAX9bncbMREqQEit9vmPxNyO-43Dw Childress test http://t3.gstatic.com/images?q=tbn:ANd9GcRFXRjstymtWRLoS5uLhYF2b-3z0tqZosEH9LK7feh4iXzq7z0_ Payer test Patella •history- retropatelar pain • kneeling, squatting, down hill gait • giwing away phenomenon •position of the patella –alta / baja) –lateral •patelar tracking •stability •Patellar retinacular ligament •Patellar facets, base, apex •FP manoeuvers (Zohlen, grinding) •Q- angle http://t1.gstatic.com/images?q=tbn:ANd9GcRGt5Vfy2mbsuD7LsPAsnHDn6KHFA61oakQ8io91JY9DvKJerCctw M 8-10 F 15 ± 5 Imaging methods •X ray, AP, lateral, axial •USG •CT , MRI •Scintigraphy •Artroscopy OO-deformity kolena Deformity of the knee joinnt genu varum /genu valgum • in children- hemiepiphyseodesis • in adults osteotomy OO- genu valgum OO- genu varum Valgus OT varus OT OO- Coventry 1 OO- Coventry 2 Meniscus •Mechanism of injury •Tests: Mc Murray • Steinmann I • Steinmann II • Appley • Turner • Payer • Childress- squat test • Meniscus •Fibrocartilago •High elasticity •Paracapsular zone • - vessels Red zone red- white zone white zone Struktura menisku lKartilaginózní struktura lRelativně acelulární - vaskulární zóna – fibroblast-like cells - avaskulární zóna – chondrocytes-like cells lKolagen. vlákna v matrix - -rozložení k přenosu kompresního tlaku + hoop stresu Functions •Bumper •Stabilisator •More congruency •Distribution of synovial fluid •LM – more mobile •MM – prone for injury Koleno menisky Typy ruptur menisku lLongitudinální lRadiální l lHorizontální lŠikmá lBucket handle lKomplexní Ruptures of menisci S2400065 •Longitudinal, horizontal, radial •„bucket handle type“ -Typical blockage •Degenerative lesions •Discoid meniscus Ruptures of menisci •Longitudinal, horizontal, radial •„bucket handle type“ -Typical blockage •Degenerative lesions •Discoid meniscus Meniscus treatment •Menisectomy •partial •subtotal •complete Partial meniscectomy S6R00004 Subtotal menisectomy Techniky sutury Outside – in Inside – out All – inside lExcelentní výsl. zhojení u mladých pac. lAll – inside – kompresní cirkumferentní steh po obvodu léze Radiální ruptura l lRpt. 60 % centrální zóny nemá vlyv na ↑ tlaku / kandidát parc. menisektomie / lRpt 90 % siginifikantně ↑ tlak – sutura lInside-out, All-inside, transtibiální technika / TT / lChronická léze – retrakce okrajů – gapping / ↓ TT / lA: Inside-out -horizontální matracový steh B: All-inside knot tying lC: Transtibiální technika outside-in inside-out all-inside Suture of meniscus- meniscopexis S6R00002 Ligaments- ACL, PCL Koleno ACL Koleno PCL Rupture of ligaments •Sprain •partial rupture • total rupture • •Mechanism of injury •Tests of stability S2400073 Unhappy trias Rupture of ACL •Tests of stability •Lachman test •Anterior drawer sign •Pivot-shift test Lachmann test Rupture of ACL •Frequent injury ACL zdravý Rupture of ACL • –Debridement –Physiotherapy –Limited activity –Orthesis balance defiancetiger6_99 Physiotherapy Orthesis Indication for reconstruction •1/3 of cases Þ BTB graft •Bone-Tendon-Bone S2400101 BTB graft •Bone-Tendon-Bone Press fit technique Hamstrings (m. semitendinosus + m. gracilis) Hamstr schema Hamstr Fixation by screws Technique ACL IS výsl S2400100 ACL plasty- press fit technique Femoral canal • Tibial canal • Tightening of the graft Graft in situ Aftertreatment •6 weeks orthesis • •Weight bearing after 6 weeks • •Sports activity after 9 months – Rupture of PCL •In dashboard injury •Posterior drawer sign ER 1 Chondropathy Outerbridge. H.K. ER 2 Chondropathy I. II. III. IV. Chondropathy I. st. S6R00001 Soft cartilage, chondromalatia Chondropathy II. st. S6R00002 Fissures in the cartilage Chondropathy III. st. •Fibrilation- „ crab meet“ Chondropathy IV. st. S6R00002 Defects to subchondral bone Defects of cartilage •Patella Medial condyle Shaving and drilling - - abraze subch Drilling - Abrasion chondroplasty ER 6 Curretage Shaver ER 7 Perforation of subchondral bone - slight bleeding Steadman, J.R., 1999 Multipotent stem cells into the defecfts The aim- to create fibrocartilago Microfractures ER 7 Microfractures ER 8 ER 10 ACI – autologous chondrocyte implantation Transplantation of autologous chondrocytes into defects of cartilage Chondrocytes in suspension under periostal layer ER ACI 1 ER ACI 4 ER ACI 4 Hangody, L., 1992 Defects up to 2 - 4 cm2 Osteochondral autograft transfer- OAT Mosaic plasty ER 12a ER 12b ER 13 ER OAT 1 OAT ER OAT 1 4 years after surgery Scaffolds- HyaloFast, Chondrotissue… Biodegradable Matrix for stem cells from bone marrow after drilling or from serum Hyalografts and chondrografts ER 16 Collagen scaffolds HyaloFast- scaffold Polymer of HA No special fixation Scaffold serves for maintaining of stem cells from bone marrow Supports viable cells Fills the defects of hyaline cartilage C:\Users\Petra Kotalíková\Desktop\surgical_training__overview__01_250x.jpg C:\Users\Petra Kotalíková\Desktop\surgical_training__overview__02_250px0.jpg Osteoarthritis FOTO 22 D:\artróza\koleno\image4.jpg Transchondral fractures abraze subch S6R00002 Removal -Subchondral abrasion -Drilling Osteochondral fractures •Removal •Fixation • • •Loose body S6R00006 Osteochondrosis dissecans •Local necrosis in subchondral bone •Mostly on medial femoral condyle •Etiology- trauma, microtraumatisation • vascular • http://www.eorthopod.com/sites/default/files/images/knee_OCD_anatomy02.jpg http://lgsmash.files.wordpress.com/2011/05/osteochondritis_dessicans.jpg •Diagnostics: • X ray, MRI, CT, artroscopy • http://images.radiopaedia.org/images/219533/d2fbda723d9371baeb5e044715eb15.jpg http://t3.gstatic.com/images?q=tbn:ANd9GcTgB0JqnPmk9bzscCs8P3xUw8QR2eDSzgvKIag55-oS_L0m7473 http://www.gvle.de/kompendium/knie/0136/2_089_078_Osteochondrosis_dissecans.jpg http://www.drdavidgeier.com/wp-content/uploads/2010/08/IMG007.jpg http://www.dr-angermueller.de/images/oesteochondrosis_1.gif RTG MRI ASC http://ajs.sagepub.com/content/34/7/1181/F3/graphic-5.large.jpg http://www.eorthopod.com/images/ContentImages/knee/knee_osteochondritis_dessicans/knee_OCD_symptoms 01.jpg ASC classification X ray classification 1.Negative 2.radiolucency 3.Sclerosis 4.Loose fragment http://ajs.sagepub.com/content/29/5/562/F2.large.jpg Therapy •Juvenile form •conservative •ASC drilling •Adult form –Drilling –Fixation of the fragment -debridement, drilling -Bone grafting -Mosaic plasty -Chondrografts http://www.eorif.com/KneeLeg/Images/OCDknee3.jpg http://www.arthros.de/Behandlung/Knorpeltransplantation/knie28.gif Patella •Chondropathy •Subluxation •Dislocation • • Chondropathy of the patella S2400114 Clinical symptoms Chondropathy of the patella •Conservative • •In lateral hyperpression • lateral release S2400113 Traumatic dislocation of the patella •Always laterally •Conservative treatment •Operative treatment S2400115 Types of patella Recurrent dislocation of the patella •posttraumatic •congenital •habitual • ASK – lateral release + medial capsuloraphy Open surgery DoleželDavid75boč Tumors •Osteosarcoma •Ewing sarcoma •Osteoclastoma •Chondrosarcoma •Soft tissue sarcomas •Bone metastases DoleželDavid75boč DistFem1 TU-TKAfem1 TU-TKAfem2 Pyogenic arthritis of the knee joint •Aspiration- bacteriological exam. •Laboratory tests •X ray, ultrasonography • •Therapy –ASC, lavage, antibiotics – orthesis – synovectomy H:\Výuka\kloub\3014[1].jpg H:\Výuka\kloub\md_09-03-0027[1].jpg Osgood Schlatter ... Other disorders •M. Osgood – Schlatter •Jumper´s knee •Baker´s pseudocyst •Bursitis •Ganglion of meniscus Entezo- Baker cysta1 C:\Users\Lukas\Pictures\JK.png https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcSR9l3x2y9DRK7uOL_QveRXtV-VY7sJnSBmM3SI7ZxYp0e I-JHo