HPI - This 34 year old lady mentioned occasional left hip and knee pain at our outpatient clinic on 2017-04. An X-ray of the left hip and knee at that point showed early stage osteonecrosis of left hip and no obvious bony lesion of the left knee. Conservative treatment was given initially. However, left knee pain worsened over the past month. Hence, she came back to our clinic. X-ray and MRI of the left knee were checked and showed osteonecrosis over the lateral & medial femoral condyle and the lateral and medial tibial plateau. She denied any autoimmune disease or steroid or alcohol consumption.
How would you manage this patient's knee pain?
HPI - A 25-year-old male presents at his general practitioner with a 3-day history of left knee pain and swelling, mainly on the anterior/medial aspect of the joint. This presentation is part of a series of self-limiting episodes, that have started since he sustained an injury (single leg landing) during a football match. At the time he was assessed in A&E with no abnormalities on physical exam and plain radiographs
Would you attempt ACL reconstruction a year after the original injury if the patient reports minimal effects in his activities of daily living?
HPI - 2 w ago patient felt intense (10/10) left knee pain while playing football without any obvious injury. Localized tender edema developed on his left upper tibila metaphysis on the medial side. After a short oral NSAID regimen and ice application his pain subsided almost completely (2/10). He underwent CT and MRI (+IV paramagnetic agent) examination
What is your opinion on cruciate ligaments integrity based on 02-21-2018 MRI sequences?
HPI - The patient is an 18-year-old male high school football player (position: offensive line) who is 18 months s/p RIGHT ACL reconstruction with an ipsilateral BTB autograft who injured his RIGHT knee while playing football.
The mechanism of injury was an opposing player landing on the outside of his leg, resulting in a valgus-type, twisting knee injury. The patient was unable to bear weight following the injury and was carted off the field.
Examination on the sideline immediately following the injury revealed a positive Lachman's and a grossly positive valgus stress test with the knee in full extension.
An MRI revealed complete rupture of the ACL graft and a grade 3 (complete) tear of the MCL.
Initial management included a hinged knee brace for 8 weeks in an attempt to treat the MCL tear conservatively.
At 8 weeks post-injury, valgus-stress radiographs (XRays shown) showed:
Medial grapping LEFT knee = 7mm
Medial gapping RIGHT knee = 15mm
A CT scan was also done to assess for osteolysis of the tunnels. Maximum tunnel diameters are 13mm (femoral tunnel) and 14mm (tibial tunnel). The position of the femoral and tibial tunnels looks adequate.
Full-length standing XRays show neutral alignment.
An MRI one day after injury reveals a complete rupture of the ACL graft and a grade 3 MCL tear, no meniscal pathology. What is your initial management of this patient?
HPI - A left knee injury occurred during a football game when he jumped over an opposing player and landed with a valgus twisting force to his left knee. He felt a pop and experienced immediate pain and swelling.
Radiographs, MRI images & arthroscopy photos are shown.
What would be your definitive management for this patient? (See arthroscopic view of meniscal tear below)
HPI - Left knee injury six years ago playing basketball, but did not seek medical attention. He continued to play basketball & volleyball despite numerous giving way episodes. He presents with pain, swelling and the feeling of instability. No specific treatment to date.
Radiographs and MRI images are shown.
At this time, how would you manage this patient?
HPI - Bad landing on right knee
How would you treat this injury? (Patient has a very promising sports career in front of him)
HPI - 36 year old, Afro-Caribbean, athletic build, in open prison at the moment.
Pain in R knee for 2-3 years. medial-sided, No sickle cell.
XRay and MRI attached.
What is your surgical management?
HPI - A 41 year old male presents with complaints of pain, limited ROM, and instability of his left knee.
The patient states that he was kicked in the knee a few months ago and developed pain in the medial compartment. He had no complaints of pain in his knee before this traumatic episode.
In August, 2016 he underwent left knee arthroscopy - torn meniscus.
In September, 2016 - re-arthroscopy - revealed a medial meniscal flap.
How would you manage this patient?
HPI - 40 year old male presents with an ongoing history of right knee pain. He describes a 2 year history of aching knee pain that has recently gotten worse after injuring his knee while lifting a heavy object at work. He works as a general laborer in a warehouse. He does not describe any mechanical symptoms related to the knee (no clicking, catching, popping, or locking). His MRI does not reveal a meniscal tear. He isolates his pain to the medial aspect of his knee.
What is the diagnosis?
HPI - A 33 year old male patient presents with a 4 year history of pain over the tibial tubercle of his right knee.
The patient works in construction as a general laborer and states that his pain has become much worse over the past few weeks.
What further imaging, if any, would you order on this patient?
HPI - 48 year old male present with a 12-month history of predominantly lateral-sided knee pain.
The pain is aggravated with activity and worse when flexing the knee beyond 80 degrees.
The patient previously underwent a left knee arthroscopy in 2011, with a partial lateral meniscectomy (posterior 1/3 80% excised).
He recently had a diagnostic arthroscopy which confirmed posterolateral wear involving both the tibial surface and the posterior aspect of the lateral femoral condyle.
What conservative treatment would you recommend, if any, in this patient?
HPI - Direct injury right thigh while playing handball 02 weeks back. Was able to continue with the game. Developed pain right thigh along with painful restriction of knee flexion. No fever.
HPI - Fell while trying to climb up a wall
How would you manage this injury?
HPI - 35M presents complaining of left knee instability.
16 years ago, he suffered an ACL tear, MCL tear, and medial meniscal tear that occurred in a motorcycle accident. Around the time of the accident (at age 20), he underwent an ACL reconstruction via transtibial drilling with an ipsilateral Bone-Patella Tendon-Bone (BTB) autograft and a partial medial meniscectomy; his MCL injury was managed non-operatively. Metallic screws were used for ACL graft fixation on both the femoral and tibial sides.
The surgery was successful and the patient achieved a full recovery, until 4 years ago when he re-injured his left knee while playing basketball. At the time of the injury, the patient noted immediate knee pain and swelling, and has since complained of subjective instability of his left knee.
An MRI reported a tear of the lateral meniscus, as well as tears of both the reconstructed ACL and the native PCL.
Given that the patient has subjective instability of his knee and has failed a course of non-operative management, how would you choose to manage this patient operatively?
HPI - Patient with pain in his groin for 6 months. He has abnormal gait pattern. Pain on his groin when adducting his thigh with a bump. He had done physical therapy with poor results.
What is the best treatment?
HPI - Knee trauma 2 weeks ago while playing sports. Felt a pop. Now has pain, swelling and limited range of motion.
Given the information above, how would you treat this athlete?
HPI - During sports activities (basketball) a 17 years old male injured his left knee. He came to my office two weeks later.
How would you treat this patient initially?
HPI - Patient 36 yo, male. 4 months ago ACL anatomic ligamentoplasty and partial meniscectomy of lateral meniscus. Due to knee stiffness, 2 manipulations under anesthesia were necessary.
Do you think this is a complete rupture or a partial rupture?
HPI - 14 year old playing soccer and sustained twisting injury. Fell to the ground. Presented to me with swollen knee. Place in KI and MRI obtained.
MRI shows significant lateral patellar subluxation with some tilt.
Trochlear dysplasia (flat trochlea)
Large medial facet chondral deficiency with loose fragment in suprapatellar pouch.
Medial patellar facet fx.
MPFL seems to be attached to medial fx fragment.
I measured TTTG to be 19-20
I did not appreciate patella alta.
What are your guys thoughts?
Scope and see if cartilage piece can be fixated?
Or let medial facet fx heal then go back and do tibial tubercle transfer with lateral release, medial plication / mpfl and denovo for chondral defect?
What would be your next step in treatment of this patient?
HPI - 26 year old male presented with recurrent left ACL rupture a year ago. Prior left ACL reconstruction using allograft, with re-rupture 3-4 months after initial procedure. Pop with acute swelling while jogging during rehabilitation, with persistent pain and instability since then. Unable to jog or do any other activities.
Prior right ACL reconstruction with autograft hamstring eight years ago, no subsequent issues with that knee.
Graft choice (ie auto vs allo)?
HPI - 55Y F, normal weight, recreative sportswoman, last 3 months nonsmoker.
Ski injury in Jan.2015
Feeling of knee instability in some activities.
Plese give me an advice to reconstruct LCA or not!
She is smoker and 55Y old.
What to do...?
HPI - 2011 was diagnosed with osteonecrosis of the right knee - no treatment then, kept bearing weight and the pain resolved - till now symptom free - ambulates well, tolerates the pain
How would you treat this patient?
HPI - 40 yr old active female with groin pain with activity. No major trauma. Pain getting worse for past few years. All in groin. + pain in groin with FADIR of hip.
Clear hip impingement but with significant protusio / global pincer.
Also with pubic symphysis sclerosis.
LCEA is 49 deg
Classic Contre-coup lesion in posteroinferior acetabulum and posteromedial femoral head.
Hip arthroscopy with acetabular bony resection? Will that lead to futher instability? Labrum will likely be ossified and crappy. Be prepared for labral reconstruction?
Send to open surgeon?
Next step after failing conservative treatement.
HPI - 46F with a chief complaint of right knee pain that began when she heard a pop while performing yoga. She states she subsequently further injured her knee while running and now has a moderate effusion as well as mechanical symptoms. She has been unable to fully extend her right knee, lacking approximately 8 degrees of terminal extension. She is otherwise healthy, enjoys running, and has a BMI of 21.
In a 46 year old avid runner with a medial bucket handle tear, what is the preferred treatment option?
HPI - 10 years ago the patient had taken chemotherapy and radiotherapy and went under a bone marrow transplantation due to ALL diagnosis. He has been totally cured for 10 years and no relapse. He has not been using any immunsuppresive agent since then. (10 years)
What would be your first choice for treatment of this patient?
HPI - Hit flexed right knee on a metal guard rail whilst skateboarding down a hill at 40 km/hr
How would you treat this injury?
HPI - Unclear history of present illness. Fell down 6 weeks ago, pt presented in the hospital 3 weeks after the injury with severe knee effusion. Had a wash out of the knee with the possible diagnosis of knee septic arthritis. He has been d/c home with oral AB. No other details are known from this admission.
Admitted again in our Hospital with ascites and severe knee effusion. Arthroscopic wash out performed again, due to suspicion of a septic knee. Cultures and fluid analysis were negative for infection.
HPI - 52 yo female anethesiologist complains of worsening R hip pain for several months. No specific injury although states that she "tweaked" it on several occasions. She is an avid, competitive tennis player
HPI - 12 month history of pain worse in the last 2 month. Manual worker. occasional amateur soccer player. no history of trauma
What would your next step in management be?
HPI - History of injury knee joint 1year back leading to instability knee joint.presence of lytic lesion incidental finding on x ray
What should be the treatment plan
HPI - 19 year old male football player, Had a atraumatic knee injury June 30,2014, while doing a sudden extension of the knee. He refers pain below the knee cap, when doing flexion and extension. He doesnt tolerate a flexion above 30°. MRI from June 30, 2014 showed a chondrol fracture (see image). He was initially treated with a knee splint, rest, for 4 weeks. After that he was allowed to walk without the splint, open chain excercise, he still have pain while flexing knee over 30°. New MRI shows that the the chondral fracture seems to be still unstable.
What should I do next?
HPI - 25 yo laborer that was dancing at his bachelor party with first-time patella dislocation. evidence of large (approx 2cm)chondral loose body from medial facet with small amount of bone attached to small portion of loose body. TT-TG ratio is normal. In addition to MPFL repair/recon how would you treat the largely chondral fragment with small amounts of bony attachment.
would your treatment include attempted fixation of segments with attached bone, debridement, OATS, microfracture?
would you use bioscrews or acutrax metal screws for any attempted refixation??
deNovo is not available due to insurance restriction.
what would your treatment be for the largely chondral defect with small areas of bony attachment?
HPI - 27 yr F. Multiple knee instability episodes. Many patellar dislocations when teenager. Was a dancer. Has generalized ligamentous laxity.
Had MPFL repair and lateral release 12 years ago. Did not do well after surgery.
Main complaint is instablity.
On exam very lax patella. + apprehension. 4 quadrant excursion.
Failed conservative tx.
+ patella alta
Caton deshamps 1.3
Trochlear dysplasia Dejour type C
+ acl tear
What to do now?
Tibial tubercle tx with distalization and revision mpfl reconstruction
When to reconstruct ACL? Do all one surgery or stage?
HPI - bike vs bus MVA 10 days ago. Was unable to bear weight on the leg immediately after the fall
How would you treat this patient`s ACL?
HPI - 17 year old obese female. BMI 37.2
Playing football with friends. Twisted knee and heard a pop and swelling.
MRI shows acl tear and medial meniscus tear, but standing xrays show significant lateral joint widening.
Full length scanogram shows significant varus alignment.
Difficult to really evaluate posterior lateral corner structures due to obese knee. I did not appreciate any increased external rotation.
What to do for this young pt?
ACL reconstruction alone?
ACL and HTO?
What surgery would you perform?
HPI - 18 yo following patella dislocation with 12x11mm chondral defect at the median ridge with several chondral loose body fragments. TTTG is 14. In addition to MPFL advancement and lateral release what would be your cartilage restoration technique of choice? Insurance carrier in this region will not pay for DeNovo.
Which cartilage restoration technique would you select?
HPI - Sustained atraumatic patellar dislocation while walking at age 10. Full dislocation, self-reduced. Underwent PT. Sustained another while running. Underwent PT. Then a third dislocation.
What is the next step in treatment?
HPI - 36 year old active male with lateral knee pain. Previous hx of acl recon. Did well with that. Recently started to have lateral knee pain.
Initial arthroscopy did reveal Grade 3-4 lateral joint chondromalacia. Well contained lesions. This was debrided and microfractured. ACL graft was intact.
Continued to have pain. all pain is lateral knee.
Now my Plan is for ACI vs DeNovo.
Full length scanogram films shows mechanical axis falls through the lateral joint. Not terrible but not normal either.
Any indication for distal femoral osteotomy along with cartilage restoration? Stage or do at same time?
Plan of care?
HPI - Insidious right knee pain without trauma 4 weeks ago
Whati is the diagnosis?
HPI - 58 yr f with lateral knee / leg pain. No trauma. Pain now getting worse.
MRI shows large proximal fibular synovial cyst. Looks like it communicates with the knee joint.
Has failed conservative treatments.
What would be the next step in the management of this patient?
HPI - 40 yo active teacher that sustained proximal hamstring avulsion 7 weeks ago. no sciatic nerve symptoms. Would you use a horizontal incision or vertical incision? Does anyone have experience with the healing rate of the T shaped incision described in Bradley's Article
Evaluation and management of hamstring injuries. Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J.
Am J Sports Med. 2013 Dec;41(12):2933-47. doi: 10.1177/0363546513487063. Epub 2013 May 23.
How would you treat this 7 week old injury?
HPI - 18 yo fell on flexed knee skateboarding.
How would you treat this PCL injury with small bony avulsion
HPI - Painless knee crepitus
What is the MRI finding?
HPI - 12 y/o male baseball player presents with his family concern of "limp" when running. No traumatic incident reported. 6 months of symptoms.
What would be your first line of treatment?
HPI - 16 y/o male playing competitive baseball. While up at bat, he completes an aggressive swing and feels a pop above his right hip. He is unable to weight bear on the right leg due to pain.
What initial treatment option would you recommend?
HPI - 21 year old female with history of recurrent dislocation patella was operated 2yrs back .lateral release ,proximal and distal alignment were performed .intraoperatively there was no dislocation. patient was asymptomatic for one year when after fall she again developed symptoms of recurrent dislocation of patella dwhich takes place in flexion beyond 100 degree
what should be the further treatment plan
HPI - H/O fall 6 months back leading to injury right kee joint.patient is having recurent episodes of knee giving way with painful episodes
what is best treatment optionin 15.5 year old
HPI - 62yo female, no sports, retired. After fall in hiperflexión of hip with extended knee, presents pain, haematoma in posterior thigh
What treatment would you choose?
HPI - 38 yr old very active with anterior knee pain for many years. Was told it was nothing by many orthopods.
Clear valgus alignment
Imaging shows patella alta with increased TTTG distance. Lateral patella facet and lateral trochlea chondral damage.
Decided to proceed with arthroscopy after initial trial of non op treatment.
What should be the next step of treatment?