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Patella Instability for Orthopaedic Exams
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Patella Instability for Orthopaedic Exams
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Language: EN.
Segment:0 .
And good evening, everybody. Welcome again to our Wednesday webinar session. Today, we're very lucky to have one of our mentors who has joined us quite a while back, actually, and we're very pleased that he can come with us today. He has been working in Cork University Hospital and he's going to give us a talk on patellar and stability before Mohammed Ansari starts his talk.
I just want to remind everyone that the right session will come at the end of this webinar and that's not recorded, so please volunteer for the hot seat session there. And also, if you have any questions, please type it in the chat and you answer the questions in the audience. Thank you very much. Am really looking forward to your talk regarding anatomy giant consist of the article surface of the patella and the article surface of the trochlear.
It is a gliding joint and they have the thickest cartilage in the body and it is a largest chesimard bone. It has two surfaces anterior and posterior and surface attachment to the quadriceps, tendon proximity and the patellar tendon destiny. While posture surface is distal, one third or 25% is non articular and the proximal or 2/3 is articular.
While the it has to face it, medial and lateral facets separated by a rich, we'll go into detail of more, more detail afterward and then the top layer is the other part of the joint, which is the article surface of the distal femur and it has a groove and the diameter of the lateral mercantile is more than the mesial epicondyle, and epicondyle is longer and higher, as we can see in the picture.
This is regarding quite a large military that it has to face it, medial lateral visit. Normally they are equal in size and they both are concave and we can classify, according to Weibull classification, the top one has equal media letters state, which both are concave, while type 2 there is middle face that is smaller than the lateral facet, but still both are concave and type III that the middle is smaller and convex as compared to the lateral side.
And then come the tropical geometry that rocklea is on the over the surface of the distal femur, and it has to reach to condyle medial lateral in the form of the ridge. And we can classify according to the general classification, and that classification is based on the CT scan or MRI. The axilo images the grade a. It is normal cochlea or shallow with shallow groove.
And if we see on the lateral view of the knee, as shown in the zygomatic representation of the x-ray, there will be no crossing sign. These two lines will not cross and grade b, this flat or convex cochlea and on the X-ray will see the crossing sign. These two lines will cross each other and grade b, these hyperplasia of the medial epicondyle so regular C they'll be hypoplastic medial epicondyle.
And this is the picture the last one, which will show that there will be the double control volume and the axilo section will be like this. Then then this is the picture where we can see the fourth classification, fourth grade grade D and we can differentiate between C and D that is in the c, the medial epicondyle, the hypoplastic, but indeed is a clear pattern we can see in these pictures.
Then regarding function of the patella, there are three main function that it provides a long liver arm for cord, which increases the power of the cord and the efficiency of the cord muscles. Second one is that it decreases the coefficient of friction cartilage on cartilage. If there is no patella, then patellar tendon or tendon has to rub against the cochlea, and that coefficient friction will be quite high as compared to coefficient of friction of the cartilage and cartilage, and determined that the was medial was the literalists and was intermediate and caused femoris.
The all attached to the patella and patella provide decentralising divergent forces by its centralizes the dominant forces of the car. These are all muscles. And then come to some of the biomechanics, which are important for the stability of the patella. There is no there is normally angle that is the angle is between two line one line drawn from the antero-supero-lateral spine to the center of patella and from center of patella, the tuberosity.
The second line. The angle between is the angle and with normal angle. Still, there is a tendency of the particular to suplex laterally. And if this angle increase, the tendency of the patella to flex laterally will increase and to keep the patella in position. They are different restraint provided by the nature. That is important for the stability of the patella, and we can classify we can divide into static and dynamic static again can be divided into bony and soft tissue and the bony the shape of the patella, as we have discussed earlier, the Viper classification medial and lateral facet.
And then secondary shape of the cochlea, according to the classification we have seen for decades. We have discussed for years then the general Wilgus or the alignment of the lower limb. That is the acute angle that I have discussed that if you only increase the latter subluxation forces will increase, then the next one is the rotational alignment of the lower limb, which is important that if this femoral antipodean and tibial extortion, that will increase the little solicitation of the patella.
And the next one is the soft tissue. They are the most important in the MPFL medial ligament that provides about 50% strength to oppose the lateral subluxation, and there is a medial retinaculum column. They also provide the stability to the patella. And then the main cluster next to the dynamic is equally slap tendon, which I already told that consists of four muscles, and they provide force to keep the patella in the center.
And the wall, says maryalice, is most important, which keep the patella. Toward the middle side and oppose the or resist the latter's opposition of the parliament, and then we can divide the patellar instability. This classification by this classification is not so common, but we can divide into these three types. Acute traumatic type and that trauma can be direct or indirect.
And mostly, it is indirect. And then the chronic claw palsy type, which is in European female with the high burden score and could be habitual, that it's pain that is painless and that is because of tight lateral structure. And then come to the assessment of the patient with the particular instability. The instability will assess with the triple assessment, history, examination and the investigation, and these guidelines are there for the instability, a assessment, and I will discuss that later on.
That is almost same, which I will tell here. The first of all, will take the history in the history important points. The h is related is important for the treatment of the political instability and also that it is less common in the old age as compared to the young age. And then is the mechanism of injury of the first event, which will dictate that what type of political instability is this one and then how many times it was dislocated?
It is the first dislocation or recurrent dislocation that will also dictate our management and then worse symptom patient can have for the patellar instability. Number one, that usually they are presented with dislocation, but they can present with the subluxation, pain or giving way also. And then also the important point that we have to inquire that does the patient have double jointed?
Yes or no? And regarding the examination of the nie, there's this in my system of examining the knee. Everybody will have his own system, but there are some important point, which we have to look. First of all, the inspection from front, from side, from back and in the inspection will look for any metal alignment, any deformity, any asymmetry.
The especially the well, obviously and the rotation of the lower limb. And then we check the gait in the gate, the important thing we have to see that is entering rexton gait. Then we'll ask the patient to sit and check for the sign that is tracking, and then we'll ask the patient to lie down and we'll do the full examination of the knee in that.
But the special interest regarding this topic is that we'll do the patellar apprehension test. Will do the blood test, which is pretty low friction tests. This is quite painful, but we have to take care, do it very gently and put a little test, will tilt the patella and see that how much it can be treated. This will tell us about the laxity of the medial lateral structures, then put a light test, will glide deeper the line.
We'll see that how much it glide to medial and lateral side. And then the producer of competition to see if there's any artistic changes have started or no? And then I'll put the patient on site and check for the ultimate tightness by the egawa test, and then I'll put the patient room to do the rotation profile and at the end biting score. Regarding investigation, there are three types in investigation investigation, which we can do X-ray, MRI and CT scan in the X-ray.
We will usually do the AP lateral weight bearing and the skyline, and sometimes we have to do the long leg film. In the latter view, we can judge different factors. One is the patellar height for that we should know that conditions ratio. And there are different ratios. Blackburn people inside celebrity and movements there are different criteria to measure the height of the Perella, which I will discuss later on.
And then we'll see the total dysplasia, which I have already mentioned that will see the cross-over sign, the well controlled sign and topless bar in Sky9 view. We will see different angle for the trochlear dysplasia. That is sulcus angle, but a little Congress angle, little angle and Peter dysplasia. And if there's any deformity, then we have to do the long leg film. To address for the different to for the more details of the deformity.
We will do the MRI scan, and there are different protocol in different hospital in my center. The protocol is that for the first dislocation, we are not doing the MRI. But if it is recurrent, we are doing the MRI scan. Second, dislocation and why would you the MRI scan, we can see the MPFL continuity and also we can see TG distance and any osteochondral lesion, any kind of arthritis.
And we can do the CT scan to see the patellar and trochlear dysplasia and to assess the distance, and this is a better way as compared to MRI to measure this one. And this is the. And this this, I will describe the drone how to measure the kitty to the distance. Then this is the X-ray of the knee.
And here it is, showing that there is. So he. Crossing sign. And this is because of the flat problem and this portable spa we can see. And there is double control, we can see which I have already mentioned in my previous slide with the help of your diagram. And this is because this double countersigned because of the hyperplasia of the medial epicondyle.
And then we can see the lateral view, right, and at 30 degrees of flexion, the movement sight line is at the level of the injury report. This is one of the criteria. Then there are different method of measuring the height of the patella, and that is one of them is the blechman index. And this is the distance between inferior pole of the patella to the article surface of the tibia and/or divided by the article surface of the patella.
The normal range is 0.5 to 1. The other one is getting the ships, and that is distance between infill pull up to the arduous surface of tibial plateau and and divided by Article Vi of the patella. This is between 0.61 0.3 and then in salivatory show, that is length of the patellar tendon divided by the length of the patella normal ranges 0.8 to 1.2. So these are the different method by which we can measure the length of the height of the patella and.
We can use any one of them. You either use the Black peel ratio or condition. And on merchant view or the skyline view, these are the different angles, which we can see, the Congress angle we can see here. This is between the two line. One is perpendicular to the cochlea, the deepest part and then one line to the thickest part of the patella at the junction of the medial lateral visit.
And we measure the Congress angle. This is the Congress angle. Then there is circle angle. This is the circle and the dotted line. And then a letter from angle from one line along the interior of the letter of the mercantile letter and medial epicondyle and one line along the letter visit. And this letter subbasement, we can see. And this is the diplomatic representation of merger of the TG distance.
We have to measure the distance between two lines one line from typekit tuberosity to the posterior cortex in one cross section of the sea and the other cross section will see one line from the local group to the posterior cortex. And that is in between these two lines. This distance? This is a TG distance.
Then come to the management, the management will be according to the bio speciality standards, and I summarizes this important point here that will patiently manage with the MDT and if need surgery, then that would be according to the cause underlying etiology. And if and should be done, this surgery should be done by a special surgeon who used to do these type of surgery.
And the next one is the pre and post op rehabilitation should be by the specialist physio. In children, we should do the final sparing procedure. We should not do the tibial tuberosity or start me or tibial transfer tuberosity transfer in children. And if we have to answer that, how I will manage the patient with particular instability, this is in general that I will manage him.
According to MDT and MBT will include the orthopedic surgeon, which orthopedic sports surgeon, which has special interests in knee surgery. And also, we have to include the specialist physio and the occupational therapist and it. Treatment will depend upon patient factor and condition factor. Patient factors include the age, the activity level and the comorbidities of the patient.
Activity level mean that if there is any, whatever it is, the sports activities, what is the occupation of the patient and regarding condition factor, that will be that if what is the underlying etiology that I will discuss now later on? The first line of treatment is physio in all the patient. And that is any muscle strengthening, especially whilst somebody else objects. And if the non-operated treatment fail.
A operative treatment. And then operative treatment would be according to the underlying etiology. This is one of the scenario, if there is a patient presented with recurrent stability and would do the MRI scan, we found that this empathy then we can do MPFL reconstruction with the help of or allograft. And in my center, we use usually the autographed hamstring graft.
And repair can only be done if there is bone microfracture or bone abrasion, fragment is there. Otherwise, reconstruction, we have to do. And other scenarios that if a patient presented and we investigated, we do the density scan and the distance is more than 20. Then we have to do a table tuberosity transfer. They are different method. One is the elmslie to transfer in which we transfer the tuberosity to the medial side.
And if there is MPFL there is there, then we have to do the NPF reconstruction also. And the second one is the Fulkerson transfer that is the intermediate transfer of the TB tuberosity plus minus MPFL reconstruction. If this particular Alta, if they get an air ratio, is more than one point three, then we can do the district transfer of transferability egawa tuberosity.
If there is better control, says early osteoarthritis, then we can do the anterior displacement of the tibia tuberosity. And that is the Fulkerson method that's intermediate transfer of the tuberosity. And if there's severe lateral compression syndrome, the latter structure tight, then theoretically, we can do the latter release, but practically nowadays we are not doing isolated that release.
It is usually indicated if there is excessive latitude or tightness after mobilization of the tuberosity. And if we found that the struggler dysplasia, then we can do the chocolate. And if patient presented late and there is a portal of management or through arthritis, then the option is the put from a joint arthroplasty. And if is osteoarthritis in the other compartment, especially in elderly, then we have to do the total knee replacement.
And if all fails, that is if there's any fracture the patella or resurfacing is not possible, then the option is to elect me. And if they shoot a child, then same principle as adults. But in general, most preserved devices do not integrate to taught me that will harm the good plate of the plasma. And if we do this to me, we have to explain to the patient that there is decreased power to 50% And this is the view, especially the standards for recurrent sensitivity assessment, and these are almost the same, which I have discussed with you in my slides.
And this is the surgical manage according to your specialist standard. This is also the same, which I mentioned in one line. And those are. That is a brief, very brief summary of this guideline. And there's all. Thank you very much. Um, thank you.
Thank you very much. That's very good. It's not an easy topic. I have to agree. When when I was reading this up, there were often multiple operations for the same pathology treatments and multiple options. Can I ask, can I ask you when you were talking about your preferences, are these things you would do normally in your practice?
Uh, no, we MPFL reconstruction. We do usually and the debate was transferred, really? We do. But really? No, I agree. I said that's what I was thinking it would be. Is there any questions from the audience? Yes, I have a couple, so thank you very much for the talk.
And it is very focused on the FRC exam. One question or merchant view skyline view sunrise view all systems. I think so, Yeah. Maybe it's a shrunken Greg, but I think they are thin. I think they're the same, but one is from one side, from the superior, while the other is from the inferior which order they are. I'm not sure which one was skyline, which one was merchant.
I think sunrise is probably the same skyline, if I remember correctly. I'll look it up and get back to you on that. I think the aim is the same as to and the angles are the same. So that's the main point is the interior pure interior transfer of the tble tuberosity. What is the name of the surgery? Is it Fulkerson or maquettes?
And should focus on intermediate transform ventromedial? Yeah Uh, Yeah. Someone has flagged it in the shed that the skyline is prone and 150 degrees of flexion. That's all the questions I have till now. Thank you. I think that is correct.
The skyline view is from while the motion view is supply, but it's pretty much it's just the way the X is taken. It gives you the same information, the same angles. So not to be missed intraoperatively anything any role for isolated medial axilo patellofemoral ligament reconstruction. We used to do if there's ample rupture there, and I have seen most of the procedure, which we do, and that is the type of reconstruction.
If it is torn. But it depends upon the underlying etiology, if there is supposed to it is existence is more than 20, then isolated MP4 extinction will not do the job. We have to address the ideology. What is the underlying pathology? Thank you. Good evening, everyone. Hi, Mr Henry.
Hi, everyone. Hi, I'm sorry. Please go ahead. I'm fine. OK, so reclassification basically about four classes of, Uh, for personal instability in general type one, where the Bachelor is the first time it's location. We meet it in the air type two, when the patient presents with recurrent lateral instability for multiple times, which is the most common type.
And it's also divided into two sections where the recurrent patella subluxation or two or more patella dislocations. Uh, my confusion is always between typekit and poor, where typekit is a dislocated patella. I believe this when the patient presents to us, to the clinic rather than the ER with passive patella dislocation or a habitual dislocation in every flexion extension, while type IV is the dislocated patella and is divided into type and b, whether it is reducible or irreducible.
So any idea about this classification and its significance to treat the patient? Or how it guides the treatment. The an issue, it is the initial classification efficiency tool that first time and second time recurrent. That is controversial. I have seen it before in some central protocol was that first dislocation. That's physiotherapy and send home if he come again, then we'll investigate further with the MRI scan.
And go for the treatment. And nowadays the trend is changing in my center also that if a young patient and this is first time dislocation, then we are doing the MRI scan. If there's a fear that we're going for the MPFL reconstruction. So I mean, this I know I don't know about the particular speech and even. So I can't see how it can guide management.
OK, thank you. Oh my, what I suggest for the folks here on the set sitting there for us. I wouldn't suggest using a first or even second of dislocation as an indication in younger patients to go to an operation. I know some centers are doing, but that's not the traditional. Knowledge that your examiners at the moment. Does that make sense? So you are perfect, senator, controversial, if you say on the first dislocation or second dislocation, you're going to go to Object because operative is an option only after exhausting non operative options.
Does that make sense? Yes, of course. If you completely agree with you two abnormalities, that non operative is not going to work. That's fine. You can argue that in the exam, but you are going it makes more sense as a safe year, one consultant to say I will exhaust non operative options and discuss this with the specialist in young terror young knee dislocation specialist.
Does that make sense? Perfect thank you very much. Any more questions? Yes OK. Yeah so for if there is any tightness in the lateral structures, what is your surgical recommendations? If there is any tightness, then we have to release.
From inside the letter writing a column which you usually would do and. I have already mentioned that there is no rule of isolated letter release. Nowadays, it is usually combined with the other procedure after doing those procedures, if still there's tightness, then we are doing that one. This is good. Thank you.
And for the immediate reconstruction would use always photographs or you can use synthetic graphics. We usually use autographed from the hamstring. Otherwise, we don't have the hamstring. If some patient is recalcitrant and bilaterally, then we have to use the synthetic. OK and if you want to distill distally translocate the typical tuberosity of the four patellar Alta, would that decrease the degree of flexion of the knee?
I would say theoretically yes, but practically, I mean, these are I have seen very few cases. Maybe one case for this transition, usually the anatomy to transfer. We have seen so I will say that I have no experience what will happen. But tragically, yes, it it looks like that it will decrease deflection. But but I have no, I can't say with a surety.
And what is the most used autographed? Is it classiness or symmetry? Cemetery symmetry? OK yeah, I think other questions are answered in other. Yeah have we answers as well. So thank you very much for that. You're welcome. Yes, thank you. I have something to add.
So regarding the CCG, actually, this paper is poor, actually, since the French paper published in 1998 and it's relied on the CT scan to measure the distance, and it ignores the cartilage thickness, which is very thick in that area. So you can mention that in the exam or if you mention that the quality of this debate is not good, it ignores the cartridge thickness and it is like a white with like the normal 10 to 15, and it was very wide range of like normal.
But I think it may give you more Market in that and don't rely on that decision. I don't think that most of the need surgeons rely in their decision nowadays. The that's correct. That's very good. Thank you. Mohammed Ansari, thank you so much. It's a very good talk, as always.
Always enjoy your presentations. Comprehensive, well orientated to the and very good set of questions from our participants. Today we had a total of 60 participants. Norway's goals I strongly recommend reviewing these figures when they come up on the YouTube channel and on our website page. Keep an eye out for further webinar sessions and dates, and please do register in advance.
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Thank you very much, everybody. Thank you so much. No other comments about this location. We pause here and start our session. Thank you, everyone.
Segment:0 .
And good evening, everybody. Welcome again to our Wednesday webinar session. Today, we're very lucky to have one of our mentors who has joined us quite a while back, actually, and we're very pleased that he can come with us today. He has been working in Cork University Hospital and he's going to give us a talk on patellar and stability before Mohammed Ansari starts his talk.
I just want to remind everyone that the right session will come at the end of this webinar and that's not recorded, so please volunteer for the hot seat session there. And also, if you have any questions, please type it in the chat and you answer the questions in the audience. Thank you very much. Am really looking forward to your talk regarding anatomy giant consist of the article surface of the patella and the article surface of the trochlear.
It is a gliding joint and they have the thickest cartilage in the body and it is a largest chesimard bone. It has two surfaces anterior and posterior and surface attachment to the quadriceps, tendon proximity and the patellar tendon destiny. While posture surface is distal, one third or 25% is non articular and the proximal or 2/3 is articular.
While the it has to face it, medial and lateral facets separated by a rich, we'll go into detail of more, more detail afterward and then the top layer is the other part of the joint, which is the article surface of the distal femur and it has a groove and the diameter of the lateral mercantile is more than the mesial epicondyle, and epicondyle is longer and higher, as we can see in the picture.
This is regarding quite a large military that it has to face it, medial lateral visit. Normally they are equal in size and they both are concave and we can classify, according to Weibull classification, the top one has equal media letters state, which both are concave, while type 2 there is middle face that is smaller than the lateral facet, but still both are concave and type III that the middle is smaller and convex as compared to the lateral side.
And then come the tropical geometry that rocklea is on the over the surface of the distal femur, and it has to reach to condyle medial lateral in the form of the ridge. And we can classify according to the general classification, and that classification is based on the CT scan or MRI. The axilo images the grade a. It is normal cochlea or shallow with shallow groove.
And if we see on the lateral view of the knee, as shown in the zygomatic representation of the x-ray, there will be no crossing sign. These two lines will not cross and grade b, this flat or convex cochlea and on the X-ray will see the crossing sign. These two lines will cross each other and grade b, these hyperplasia of the medial epicondyle so regular C they'll be hypoplastic medial epicondyle.
And this is the picture the last one, which will show that there will be the double control volume and the axilo section will be like this. Then then this is the picture where we can see the fourth classification, fourth grade grade D and we can differentiate between C and D that is in the c, the medial epicondyle, the hypoplastic, but indeed is a clear pattern we can see in these pictures.
Then regarding function of the patella, there are three main function that it provides a long liver arm for cord, which increases the power of the cord and the efficiency of the cord muscles. Second one is that it decreases the coefficient of friction cartilage on cartilage. If there is no patella, then patellar tendon or tendon has to rub against the cochlea, and that coefficient friction will be quite high as compared to coefficient of friction of the cartilage and cartilage, and determined that the was medial was the literalists and was intermediate and caused femoris.
The all attached to the patella and patella provide decentralising divergent forces by its centralizes the dominant forces of the car. These are all muscles. And then come to some of the biomechanics, which are important for the stability of the patella. There is no there is normally angle that is the angle is between two line one line drawn from the antero-supero-lateral spine to the center of patella and from center of patella, the tuberosity.
The second line. The angle between is the angle and with normal angle. Still, there is a tendency of the particular to suplex laterally. And if this angle increase, the tendency of the patella to flex laterally will increase and to keep the patella in position. They are different restraint provided by the nature. That is important for the stability of the patella, and we can classify we can divide into static and dynamic static again can be divided into bony and soft tissue and the bony the shape of the patella, as we have discussed earlier, the Viper classification medial and lateral facet.
And then secondary shape of the cochlea, according to the classification we have seen for decades. We have discussed for years then the general Wilgus or the alignment of the lower limb. That is the acute angle that I have discussed that if you only increase the latter subluxation forces will increase, then the next one is the rotational alignment of the lower limb, which is important that if this femoral antipodean and tibial extortion, that will increase the little solicitation of the patella.
And the next one is the soft tissue. They are the most important in the MPFL medial ligament that provides about 50% strength to oppose the lateral subluxation, and there is a medial retinaculum column. They also provide the stability to the patella. And then the main cluster next to the dynamic is equally slap tendon, which I already told that consists of four muscles, and they provide force to keep the patella in the center.
And the wall, says maryalice, is most important, which keep the patella. Toward the middle side and oppose the or resist the latter's opposition of the parliament, and then we can divide the patellar instability. This classification by this classification is not so common, but we can divide into these three types. Acute traumatic type and that trauma can be direct or indirect.
And mostly, it is indirect. And then the chronic claw palsy type, which is in European female with the high burden score and could be habitual, that it's pain that is painless and that is because of tight lateral structure. And then come to the assessment of the patient with the particular instability. The instability will assess with the triple assessment, history, examination and the investigation, and these guidelines are there for the instability, a assessment, and I will discuss that later on.
That is almost same, which I will tell here. The first of all, will take the history in the history important points. The h is related is important for the treatment of the political instability and also that it is less common in the old age as compared to the young age. And then is the mechanism of injury of the first event, which will dictate that what type of political instability is this one and then how many times it was dislocated?
It is the first dislocation or recurrent dislocation that will also dictate our management and then worse symptom patient can have for the patellar instability. Number one, that usually they are presented with dislocation, but they can present with the subluxation, pain or giving way also. And then also the important point that we have to inquire that does the patient have double jointed?
Yes or no? And regarding the examination of the nie, there's this in my system of examining the knee. Everybody will have his own system, but there are some important point, which we have to look. First of all, the inspection from front, from side, from back and in the inspection will look for any metal alignment, any deformity, any asymmetry.
The especially the well, obviously and the rotation of the lower limb. And then we check the gait in the gate, the important thing we have to see that is entering rexton gait. Then we'll ask the patient to sit and check for the sign that is tracking, and then we'll ask the patient to lie down and we'll do the full examination of the knee in that.
But the special interest regarding this topic is that we'll do the patellar apprehension test. Will do the blood test, which is pretty low friction tests. This is quite painful, but we have to take care, do it very gently and put a little test, will tilt the patella and see that how much it can be treated. This will tell us about the laxity of the medial lateral structures, then put a light test, will glide deeper the line.
We'll see that how much it glide to medial and lateral side. And then the producer of competition to see if there's any artistic changes have started or no? And then I'll put the patient on site and check for the ultimate tightness by the egawa test, and then I'll put the patient room to do the rotation profile and at the end biting score. Regarding investigation, there are three types in investigation investigation, which we can do X-ray, MRI and CT scan in the X-ray.
We will usually do the AP lateral weight bearing and the skyline, and sometimes we have to do the long leg film. In the latter view, we can judge different factors. One is the patellar height for that we should know that conditions ratio. And there are different ratios. Blackburn people inside celebrity and movements there are different criteria to measure the height of the Perella, which I will discuss later on.
And then we'll see the total dysplasia, which I have already mentioned that will see the cross-over sign, the well controlled sign and topless bar in Sky9 view. We will see different angle for the trochlear dysplasia. That is sulcus angle, but a little Congress angle, little angle and Peter dysplasia. And if there's any deformity, then we have to do the long leg film. To address for the different to for the more details of the deformity.
We will do the MRI scan, and there are different protocol in different hospital in my center. The protocol is that for the first dislocation, we are not doing the MRI. But if it is recurrent, we are doing the MRI scan. Second, dislocation and why would you the MRI scan, we can see the MPFL continuity and also we can see TG distance and any osteochondral lesion, any kind of arthritis.
And we can do the CT scan to see the patellar and trochlear dysplasia and to assess the distance, and this is a better way as compared to MRI to measure this one. And this is the. And this this, I will describe the drone how to measure the kitty to the distance. Then this is the X-ray of the knee.
And here it is, showing that there is. So he. Crossing sign. And this is because of the flat problem and this portable spa we can see. And there is double control, we can see which I have already mentioned in my previous slide with the help of your diagram. And this is because this double countersigned because of the hyperplasia of the medial epicondyle.
And then we can see the lateral view, right, and at 30 degrees of flexion, the movement sight line is at the level of the injury report. This is one of the criteria. Then there are different method of measuring the height of the patella, and that is one of them is the blechman index. And this is the distance between inferior pole of the patella to the article surface of the tibia and/or divided by the article surface of the patella.
The normal range is 0.5 to 1. The other one is getting the ships, and that is distance between infill pull up to the arduous surface of tibial plateau and and divided by Article Vi of the patella. This is between 0.61 0.3 and then in salivatory show, that is length of the patellar tendon divided by the length of the patella normal ranges 0.8 to 1.2. So these are the different method by which we can measure the length of the height of the patella and.
We can use any one of them. You either use the Black peel ratio or condition. And on merchant view or the skyline view, these are the different angles, which we can see, the Congress angle we can see here. This is between the two line. One is perpendicular to the cochlea, the deepest part and then one line to the thickest part of the patella at the junction of the medial lateral visit.
And we measure the Congress angle. This is the Congress angle. Then there is circle angle. This is the circle and the dotted line. And then a letter from angle from one line along the interior of the letter of the mercantile letter and medial epicondyle and one line along the letter visit. And this letter subbasement, we can see. And this is the diplomatic representation of merger of the TG distance.
We have to measure the distance between two lines one line from typekit tuberosity to the posterior cortex in one cross section of the sea and the other cross section will see one line from the local group to the posterior cortex. And that is in between these two lines. This distance? This is a TG distance.
Then come to the management, the management will be according to the bio speciality standards, and I summarizes this important point here that will patiently manage with the MDT and if need surgery, then that would be according to the cause underlying etiology. And if and should be done, this surgery should be done by a special surgeon who used to do these type of surgery.
And the next one is the pre and post op rehabilitation should be by the specialist physio. In children, we should do the final sparing procedure. We should not do the tibial tuberosity or start me or tibial transfer tuberosity transfer in children. And if we have to answer that, how I will manage the patient with particular instability, this is in general that I will manage him.
According to MDT and MBT will include the orthopedic surgeon, which orthopedic sports surgeon, which has special interests in knee surgery. And also, we have to include the specialist physio and the occupational therapist and it. Treatment will depend upon patient factor and condition factor. Patient factors include the age, the activity level and the comorbidities of the patient.
Activity level mean that if there is any, whatever it is, the sports activities, what is the occupation of the patient and regarding condition factor, that will be that if what is the underlying etiology that I will discuss now later on? The first line of treatment is physio in all the patient. And that is any muscle strengthening, especially whilst somebody else objects. And if the non-operated treatment fail.
A operative treatment. And then operative treatment would be according to the underlying etiology. This is one of the scenario, if there is a patient presented with recurrent stability and would do the MRI scan, we found that this empathy then we can do MPFL reconstruction with the help of or allograft. And in my center, we use usually the autographed hamstring graft.
And repair can only be done if there is bone microfracture or bone abrasion, fragment is there. Otherwise, reconstruction, we have to do. And other scenarios that if a patient presented and we investigated, we do the density scan and the distance is more than 20. Then we have to do a table tuberosity transfer. They are different method. One is the elmslie to transfer in which we transfer the tuberosity to the medial side.
And if there is MPFL there is there, then we have to do the NPF reconstruction also. And the second one is the Fulkerson transfer that is the intermediate transfer of the TB tuberosity plus minus MPFL reconstruction. If this particular Alta, if they get an air ratio, is more than one point three, then we can do the district transfer of transferability egawa tuberosity.
If there is better control, says early osteoarthritis, then we can do the anterior displacement of the tibia tuberosity. And that is the Fulkerson method that's intermediate transfer of the tuberosity. And if there's severe lateral compression syndrome, the latter structure tight, then theoretically, we can do the latter release, but practically nowadays we are not doing isolated that release.
It is usually indicated if there is excessive latitude or tightness after mobilization of the tuberosity. And if we found that the struggler dysplasia, then we can do the chocolate. And if patient presented late and there is a portal of management or through arthritis, then the option is the put from a joint arthroplasty. And if is osteoarthritis in the other compartment, especially in elderly, then we have to do the total knee replacement.
And if all fails, that is if there's any fracture the patella or resurfacing is not possible, then the option is to elect me. And if they shoot a child, then same principle as adults. But in general, most preserved devices do not integrate to taught me that will harm the good plate of the plasma. And if we do this to me, we have to explain to the patient that there is decreased power to 50% And this is the view, especially the standards for recurrent sensitivity assessment, and these are almost the same, which I have discussed with you in my slides.
And this is the surgical manage according to your specialist standard. This is also the same, which I mentioned in one line. And those are. That is a brief, very brief summary of this guideline. And there's all. Thank you very much. Um, thank you.
Thank you very much. That's very good. It's not an easy topic. I have to agree. When when I was reading this up, there were often multiple operations for the same pathology treatments and multiple options. Can I ask, can I ask you when you were talking about your preferences, are these things you would do normally in your practice?
Uh, no, we MPFL reconstruction. We do usually and the debate was transferred, really? We do. But really? No, I agree. I said that's what I was thinking it would be. Is there any questions from the audience? Yes, I have a couple, so thank you very much for the talk.
And it is very focused on the FRC exam. One question or merchant view skyline view sunrise view all systems. I think so, Yeah. Maybe it's a shrunken Greg, but I think they are thin. I think they're the same, but one is from one side, from the superior, while the other is from the inferior which order they are. I'm not sure which one was skyline, which one was merchant.
I think sunrise is probably the same skyline, if I remember correctly. I'll look it up and get back to you on that. I think the aim is the same as to and the angles are the same. So that's the main point is the interior pure interior transfer of the tble tuberosity. What is the name of the surgery? Is it Fulkerson or maquettes?
And should focus on intermediate transform ventromedial? Yeah Uh, Yeah. Someone has flagged it in the shed that the skyline is prone and 150 degrees of flexion. That's all the questions I have till now. Thank you. I think that is correct.
The skyline view is from while the motion view is supply, but it's pretty much it's just the way the X is taken. It gives you the same information, the same angles. So not to be missed intraoperatively anything any role for isolated medial axilo patellofemoral ligament reconstruction. We used to do if there's ample rupture there, and I have seen most of the procedure, which we do, and that is the type of reconstruction.
If it is torn. But it depends upon the underlying etiology, if there is supposed to it is existence is more than 20, then isolated MP4 extinction will not do the job. We have to address the ideology. What is the underlying pathology? Thank you. Good evening, everyone. Hi, Mr Henry.
Hi, everyone. Hi, I'm sorry. Please go ahead. I'm fine. OK, so reclassification basically about four classes of, Uh, for personal instability in general type one, where the Bachelor is the first time it's location. We meet it in the air type two, when the patient presents with recurrent lateral instability for multiple times, which is the most common type.
And it's also divided into two sections where the recurrent patella subluxation or two or more patella dislocations. Uh, my confusion is always between typekit and poor, where typekit is a dislocated patella. I believe this when the patient presents to us, to the clinic rather than the ER with passive patella dislocation or a habitual dislocation in every flexion extension, while type IV is the dislocated patella and is divided into type and b, whether it is reducible or irreducible.
So any idea about this classification and its significance to treat the patient? Or how it guides the treatment. The an issue, it is the initial classification efficiency tool that first time and second time recurrent. That is controversial. I have seen it before in some central protocol was that first dislocation. That's physiotherapy and send home if he come again, then we'll investigate further with the MRI scan.
And go for the treatment. And nowadays the trend is changing in my center also that if a young patient and this is first time dislocation, then we are doing the MRI scan. If there's a fear that we're going for the MPFL reconstruction. So I mean, this I know I don't know about the particular speech and even. So I can't see how it can guide management.
OK, thank you. Oh my, what I suggest for the folks here on the set sitting there for us. I wouldn't suggest using a first or even second of dislocation as an indication in younger patients to go to an operation. I know some centers are doing, but that's not the traditional. Knowledge that your examiners at the moment. Does that make sense? So you are perfect, senator, controversial, if you say on the first dislocation or second dislocation, you're going to go to Object because operative is an option only after exhausting non operative options.
Does that make sense? Yes, of course. If you completely agree with you two abnormalities, that non operative is not going to work. That's fine. You can argue that in the exam, but you are going it makes more sense as a safe year, one consultant to say I will exhaust non operative options and discuss this with the specialist in young terror young knee dislocation specialist.
Does that make sense? Perfect thank you very much. Any more questions? Yes OK. Yeah so for if there is any tightness in the lateral structures, what is your surgical recommendations? If there is any tightness, then we have to release.
From inside the letter writing a column which you usually would do and. I have already mentioned that there is no rule of isolated letter release. Nowadays, it is usually combined with the other procedure after doing those procedures, if still there's tightness, then we are doing that one. This is good. Thank you.
And for the immediate reconstruction would use always photographs or you can use synthetic graphics. We usually use autographed from the hamstring. Otherwise, we don't have the hamstring. If some patient is recalcitrant and bilaterally, then we have to use the synthetic. OK and if you want to distill distally translocate the typical tuberosity of the four patellar Alta, would that decrease the degree of flexion of the knee?
I would say theoretically yes, but practically, I mean, these are I have seen very few cases. Maybe one case for this transition, usually the anatomy to transfer. We have seen so I will say that I have no experience what will happen. But tragically, yes, it it looks like that it will decrease deflection. But but I have no, I can't say with a surety.
And what is the most used autographed? Is it classiness or symmetry? Cemetery symmetry? OK yeah, I think other questions are answered in other. Yeah have we answers as well. So thank you very much for that. You're welcome. Yes, thank you. I have something to add.
So regarding the CCG, actually, this paper is poor, actually, since the French paper published in 1998 and it's relied on the CT scan to measure the distance, and it ignores the cartilage thickness, which is very thick in that area. So you can mention that in the exam or if you mention that the quality of this debate is not good, it ignores the cartridge thickness and it is like a white with like the normal 10 to 15, and it was very wide range of like normal.
But I think it may give you more Market in that and don't rely on that decision. I don't think that most of the need surgeons rely in their decision nowadays. The that's correct. That's very good. Thank you. Mohammed Ansari, thank you so much. It's a very good talk, as always.
Always enjoy your presentations. Comprehensive, well orientated to the and very good set of questions from our participants. Today we had a total of 60 participants. Norway's goals I strongly recommend reviewing these figures when they come up on the YouTube channel and on our website page. Keep an eye out for further webinar sessions and dates, and please do register in advance.
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