Sm Caq - Patellofemoral And Meniscus

Front 1

Passive restraints to patellofemoral?

Back 1

1) Medial patelloFEMORAL ligament
2) Medial patelloTIBIAL laigament
3) Medial patelloMENICSAL ligament
4) Medial retinaculum
5) vastus medialis (mostly dynamic)

Front 2

Layer 2 knee medial?

Back 2

Vastus medialis
Medial patellofemoral ligament

Front 3

What stability does MPFL give to lateral translation of patella?

Back 3

53-60% or resistance to lateral translation

Front 4

Blood supply femoral trochlea?

Back 4

geniculate complex

Front 5

Where is PF pressure highest?

Back 5

60-90 degrees.
20 degrees patella engages trochlea
90 degrees quat tendon contacts femur

Front 6

PF joint reactive forces level walking?

Back 6

0.5 x BW

Front 7

PF joint reactive forces stair climbing?

Back 7

3.3 x BW

Front 8

PF joint reactive forces ISOMETRIC contraction?

Back 8

6.5 x BW

Front 9

PF joint reactive forces SQUATTING?

Back 9

7.8 x BW

Front 10

angle VMO attaches?

Back 10

55-70 degrees

Front 11

effect patella has on quad?

Back 11

patella increases the lever arm of the quadriceps muscle.

Front 12

What is the primary restraint against lateral patellar displacement?

Back 12

patellofemoral ligament

Front 13

At what degree flexion in a normal knee does the patella become centralized in the trochlea?

Back 13

15-20 degrees

Front 14

During arthroscopy with 60mm fluid pressure the patella will normally be centalized by:?

Back 14

45 degrees flexion

Front 15

Relationship thickness of central quadriceps tendon to patellar tendon?

Back 15

twice as thick as the patellar tendon

Front 16

lateral view PT length?

Back 16

4.6 cm

Front 17

patellar height ratio? (Blackburne-Peel)

Back 17

A/B
A=perpendicular distance from the lowest articular margin of hte patella to the lateral tibial plateau.
B= length of the articular cartilage of the patella

Front 18

Def Patella Baja and Alta by Blackburne-Peel ratio?

Back 18

Baja < 0.8
Alta > 1.0

Front 19

12 yo football player w sudden inc R knee pain while blocking. Knee xrays N. Knee exam N. Gait antalgic. Next step?

Back 19

xrays AP pelvis and lateral R hip

Front 20

External tibial torsion ass'd w ?

Back 20

PF symptoms

Front 21

Lateral patellar facet pressure syndrome?

Back 21

-only indication for lateral release
-tight lateral retinaculum
- lateral tilt w/o subluxation

Front 22

Where does lateral retinacular release transfer the pressune to?

Back 22

Distal medial.

Front 23

What condition is lateral release appropriate for?

Back 23

Relief of pain from bipartitie patella.

Front 24

What is procedure of choice for iatrogenic medial patellar subluxation?

Back 24

Reconstruction of lateral PF ligament

Front 25

Optimal Fulkerson tibial tubercle transfer?

Back 25

1.0 cm anterior
0.5-1.0 cm medial

Front 26

Q: Anterior translation of the tibial tubercle by 1.25cm will decrease contact forces on which portion of the patella the greatest?

Back 26

Distal.!

Front 27

Anteromedial tibial tubercle transfer best unloads which damaged patellar articular surface?

Back 27

Distal and lateral.

Front 28

Major injured structure and location for acute primary lateral patellar dislocation?

Back 28

MPFL (87-100%) usually at the FEMORAL attachment.
note: 95% ass'd chondral damage

Front 29

Acute dislocation of the patella is ass'd w what % MRI documented injury to the MPFL?

Back 29

greater than 85%

Front 30

When scope an acute lateral dislocation?

Back 30

IF osteochondral fracture, loose bodies, predisposing factors?, high demand athlete?

Front 31

Operative treatment for acute PF lateral dislocation?

Back 31

MPFL (femur, patella, or both)

Front 32

Following acute lateral traumatic patellar dislocation, the most important injured structure relating to future instability of thePF joint is the:___?

Back 32

Medial patellofemoral ligament!

Front 33

18yo w first PF lateral dislocation that required reduction on sidelines. How counsel athlete regarding treatment options?

Back 33

Nonoperative treatment is preferred over surgery! (p376)

Front 34

Q: 16yo w first lat dislocation patella requiring closed reduction in ER. Post-red shows osseous fragment inferior to patella (p376). first dislocation: what is appropriate initial treatment?

Back 34

ORIF of patella (presumably osteochondral fragment).

Front 35

risk of recurrence for PF dislocation?

Back 35

2-5 years 50%

Front 36

variables for surgical procedure for recurrent patellar dislocation?

Back 36

-limb alignment
-femoral version
-tibial tubercle position
-patellar/trochlear morphology
-patellar tendon length

Front 37

Indications for tibial tubercle osteotomy?

Back 37

-Tubercle/sulcus angle >12 deg
-ATT-TG distance >20mm
Blackburne-Peel ratio >1.2

Front 38

surgical Rx for excessive genu valgum or femoral anterversion?

Back 38

Femoral osteotomy - varus-producing and derotational

Front 39

MPFL reconstruction?

Back 39

single semiT autograft
**anatomic tunnel placement
** careful not to overtension

Front 40

technical considerations to fingig ANATOMIC femoral origin?

Back 40

Use Fluoroscopy!!
1.3mm anterior
2.6 mm proximal.
attach suture from the patellar socket to the femoral guidepin.
readjust the femoral pin until the distance between attachment sites is LONGEST NEAR EXTENSION & becomes shorter with flexion
-tension ligament at 20deg (pat engaged in groove) to recreate a one quadrant lateral glide.

Front 41

16yo female w recurrent dislocation, failed nonop mgmt, Q angle 5 degrees, closed physes. Surgery indicated?

Back 41

Proximal realignment!

Front 42

15yo male wrestler w patellar dislocation, osteochondral fragment: Rx?

Back 42

ORIF fragment

Front 43

Incidence of suprapatellar, medial, and infrapatellra plicae?

Back 43

~90% asymptomatic knees

Front 44

48yo runner w Hx patellar tendinitis whcih has resolved and not asymptomatic.MRI-->? How to decrease symptoms?

Back 44

infrapatellar strap, stretch and strengthening exercises

Front 45

Osgood-Schlatter which has failed nonoperative mgmt?

Back 45

debridement and repair

Front 46

Associated injuries to rule out w Tibial Tubercle Avulsion in adolescent.

Back 46

ACL
Collateral ligaments
patellar tendon in 10%

Front 47

Indications for ORIF in tibial tubercle Fx's?

Back 47

displaced fragments involving physis or tibial plateau
-use cortical lag screws or cannulated screws
-avoid prox tibial physis

Front 48

Blood supply for patellar Fx?

Back 48

functional blood supply from DISTAL to proximal
(anterior tibial recurrent a. Save distal fragment!)

Front 49

53 yo runner w ant knee pain. MRI shows Quad tendon partial detachment. Class abiotics ass'd w tendon disruption?

Back 49

**Fluoroquinalones !!!** (he was taking them for sinus infx, but this is a known complication of treatment)

Front 50

18yo makle w knee pain/giveway x 6 mo's despite rest and rehab. MRI p 382. Recommend?

Back 50

arthroscopy and debride/excision

Front 51

In rabbit studies patellar tendons treated w RF thermal energy...?

Back 51

stretched out w early motion!

Front 52

14yo male R knee inj jumping off platform. knee gave w landing. Xray-->tibial tubercl avulsion. Rx?

Back 52

ORIF w cannulated screws

Front 53

Important consideration for excision bipartite patella?

Back 53

excise symptomatic fragment, but preserve or repair the vastus lateralis insertion.

Front 54

Study to Dx bipartite patella vs Fx?

Back 54

triple phase bone scan

Front 55

Which areal of patella does a defect respond best to Fulkerson (anteromedialization) tibial tubercle osteotomy?

Back 55

medial facet

Front 56

Indications PF arthroplasty?

Back 56

-advanced, isolated PF arthritis
-failed nonop mgmt
-N tib/fem alignment
-satisfactory motion

Front 57

PF Arthroplasty contraindications?

Back 57

-early OA
-tib/fem OA
-inflamm arthropathy
-uncorrected malalignment/instab
-chronic regional pain syndrome

Front 58

Use of knee arthroscopy following TKA is most effective in treating which of the following conditions?

Back 58

Patellar clunk syndrome (p385)

Front 59

composition meniscus?

Back 59

65-70% water
90% TYPE I collagen

Front 60

meniscofemoral ligaments?

Back 60

arise from the posterio lateral meniscus and attach to lateral femoral condyle\
**Humphrey - anterior to PCL(50%)
**Wrisberg - posterior to PCL (76%)

**ALPHABETICAL!!**

Front 61

AP translation of Medial Meniscus?

Back 61

2-5mm. Decreased mobility contributes to higher incidence of MM tears!

Front 62

Inter-meniscal ligament?

Back 62

connects MM anterior horn to LM ant horn
**AP translation 9-11mm

Front 63

blood supply to menisci?

Back 63

-med and lat inf geniculate a's supply capsule and ant portion meniscus
-middle geniculate a supplies post portion menisci

Front 64

results of Total Menisectomy?

Back 64

-RARELY INDICATED!!
-contact area reduced 75%
-peak load increased 235%
-ACL graft forces increased 33-50%
-radiographic Fairbank Changes=post-menisectomy arthritis

Front 65

How does motion of lateral meniscus compare to medial?

Back 65

More mobile!

Front 66

most common attachments for ant inter-meniscal lig of knee?

Back 66

Ant horn MM & ant margin LM

Front 67

Which meniscus is more vascular?

Back 67

MM.

Front 68

arrangement of fibers in men?

Back 68

The circumferentially arranged longitudinal fibers serve to dissipate hoop stresses and contribute to the lead-bearing ability of the menisci

Front 69

The MM, as compared to LM,has?

Back 69

covers less of the tibial plateau surface.

Front 70

characteristics of motion of menisci during knee flexion?

Back 70

Increased motion in the posterior horn of the lateral meniscus compared with the posterior horn of the medial meniscus.

Front 71

True statements regarding menisci?

Back 71

the vascular supply originates predominantly from the inf and sup branches of the medial and lateral genicular arteries.

Front 72

Biomechanical relationship ACL/MM?

Back 72

Forces in the medial meniscus are doubled with transection of the ACL

Front 73

Which portion of the meniscus is most important secondary restraint to ant tibial translation?

Back 73

**Post horn of MM!**

Front 74

% positive MRI for MMT in >45yo?

Back 74

36%!

Front 75

recent study 31 pts w ant horn tears MM on MRI but only 8 were found to have a true tear. Therefor pos predictive value is__?

Back 75

Approximately 25%.

Front 76

10yo w pos exam, neg MRI, what is true?

Back 76

clinical exam is more sensitive than MRI

Front 77

most common type degen tears in >40yo?

Back 77

horizontal cleavage, flap, & complex tears most common.

Front 78

Characteristic of traumatic meniscal tears?

Back 78

vertical longitudinal tears.

Front 79

meniscal repair indications?

Back 79

1) unstable, full-thickness tears within 5mm of the meniscosynovial jct
2) the ability to technically stabilize and coaptte the tear

Front 80

ideal tear to repair?

Back 80

10-25% from capsular margin
young pt
stable knee

Front 81

contraindications to meniscal repair?

Back 81

-partial thickness
-short, longitudinal tears
-radial tears
-deg,macerated tears
-horizontal cleavage tears

Front 82

Most sig factors for meniscus healing?

Back 82

rim width
intact ACL

Front 83

Meniscal healing enhancement?

Back 83

-hemarthrosis (eg w ACL)
synovial abrasion
trephination of rim
vascular access channels
fibrin clot
PRP

Front 84

Healing %meniscus?

Back 84

-90% when performed in conjunction w ACL reconstruction
-50-75% for an isolated repair

Front 85

risk for posteromedial incision for MM repair?

Back 85

saphenous n (infrapatellar br)

Front 86

Inside-out Posterolateral Incision?

Back 86

-3cm vertical incision (post to FCL)
-dissect between ITB and biceps or split ITB in line w fibers
-beware peroneal n
-dissect deep to lateral gastrocnemius
-stay ant to biceps tendon

Front 87

which sutures for men rep have highest pullout strength?

Back 87

stacked vertical mattress

Front 88

Q; When performig an inside-out lateral meniscal repair the capsule exposture is provided by developing the...?

Back 88

ITB and biceps tendon interval, then retracting the lateral head of the gastrocnemius anteriorly

Front 89

What complication is more likely w inside-out MMT repair?

Back 89

saphenous nerve injury

Front 90

Important consideration for partial menisectomies?

Back 90

the meniscocapsular junction should be protected.

Front 91

Which factor is favorable prognostic factor for healing with meniscal repair?

Back 91

Peripheral rim width less than 4mm. (p396)

Front 92

Inside-out LM repair?

Back 92

The incision is post to the LCL.
(p 397)

Front 93

Meniscal-repair technique w highest biomchanical strength?

Back 93

Vertical mattress suture!

Front 94

Structure most commonly injured during MM repair?

Back 94

Saphenous n

Front 95

ACL w concomitant 1 cm tear of PHLM (stable to probe). Tear is beyond popliteal hiatus and dirsrupts small portion of root of the meniscus. Most appropriate mgmt?

Back 95

ACL recon w no Rx meniscus

Front 96

12yo w ACL/ LM. Rx?

Back 96

LM repair, w intra-artic ACL con w semi-T autograft, over the top femoral position, and extraphyseal fixation

Front 97

JLT w ACL in adolescent?

Back 97

not reliable to evaluate for meniscus tear.

Front 98

Surgical treatment of meniscal cyst?

Back 98

-remove teh degenerated and torn portion of the meniscus back to bleeding capsule
-decompress the cyst
-scarring of the cyst opeintg prevents recurrence

Front 99

What is true about meniscal cysts?

Back 99

Ther are filled with a gel-like materail biochemically similar to synovial fluid.

Front 100

43yo soccer player, s/p menisectomy x 6 mos, posterio knee pain. Equivocal PE. Next step?

Back 100

MRI

Front 101

Discoid meniscus types?

Back 101

I: complete
II: incomplete
III: Wrisberg ligament (UNSTABLE due to lack of posterior tibial attachment)

Front 102

Rx symptomatic discoid meniscus types I & II?

Back 102

arthro partial men to create a stable, balanced rim

Front 103

Rx symptomatic discoid meniscus type III?

Back 103

partial menisectomy and posterior horn suture stabilization

Front 104

Meniscal allograft indications?

Back 104

-previous menisectomy
-unicompartmental pain
-failed nonoperative program
-closed physes to ~age 45
-normal/near normal alignment
-stable knee or combined ligament surgery

Front 105

Meniscal allograft contraindications?

Back 105

-inflammatory arthropathy
-crystalline arthropathy (gout)
-UNCORRECTED malalignment
-obesity
-previous infection
-advanced arthritis

Front 106

Best choice for meniscal allograft?

Back 106

Fresh-Frozen!!
AVOID irradiated, freeze-dried and glutaraldehyde-preserved grafts

Front 107

Immunology meniscal allograft

Back 107

meniscus cells, express HLA, classI/II
antigens

Front 108

Meniscal allograft clinical results?

Back 108

80% success rate for pain relief

Front 109

Conclusions Meniscal Allograft:

Back 109

Use fresh frozen or cryopreserved, non-irradiated grafts with bone attachments

Front 110

What is the most critica factor for success of a menical allograft tranplantation?

Back 110

Accurate graft size

Front 111

Most significant contra-indication to allograft medial meniscal transplantation?

Back 111

Gr IV articular changes of medial compartment

Front 112

Meniscal allograft transplantation is most successful when...?

Back 112

Ant and post horns ar securely attached

Front 113

True statement regarding meniscal allograft transplantations?

Back 113

proteoglycan content decreases while wate content increases within the transplanted meniscus by 6 mos

Front 114

Most common complication when performing meniscal allograft transplantation with a lyophilized graft?

Back 114

Graft shrinkage

Front 115

Accurate statement regarding meniscal transplantation?

Back 115

Meniscal transplants heal well to the hoint capsule in more than 90% of patients.