The vastus medialis muscle is the retinaculum of the patella. What is the patella, where is it located, its structure and anatomy

A) Main indications:
Alloarthroplasty
Synovectomy
Arthrodesis
Expansion of minimally invasive approaches

b) Patient position and incision for the medial parapatellar approach to the knee joint. The patient lies on his back with his legs extended and loosely covered. The skin incision begins 5 cm proximal to the edge of the patella, approximately in the middle, and goes in an arc 1 cm medial to the inner edge of the patella in a distal direction, to then again pass from the medial side at the patellar ligament to the tibial tuberosity.

If exposure of the crow's foot (pes anserinus) and medial tendon-ligamentous apparatus is necessary, the incision can be extended distally. The subcutaneous layer is separated back and forth, then the infrapatellar branch of the saphenous nerve is isolated.

Medial parapatellar approach.
The skin incision can be made in an arcuate manner medial to the patella or longitudinally above the patella (left knee).
It may be extended to highlight the crow's foot or the medial capsuloligamentous apparatus.

V) Isolation of the knee joint. The medial retinaculum of the patella is incised 2 cm medial to the edge of the patella. Then the joint capsule is bluntly removed with scissors from the retinaculum and the quadriceps tendon. The knee joint traction device is reinforced at the level of the proximal edge of the patella with securing threads to ensure correct closure of the retinaculum. The quadriceps tendon is then incised a few millimeters lateral to the origin of the vastus medialis.

The joint capsule opens approximately 2 cm proximal to the medial joint space. When dissecting the synovial capsule in the distal direction, the attachment site of the anterior horn of the meniscus should be taken into account. The kneecap can now be supported laterally and rotated 180°.

If luxation of the kneecap and its lateral rotation are not possible, the incision of the quadriceps tendon and joint capsule should be extended proximally. During repeated interventions, it is sometimes necessary to perform a release in the area of the Hoffa fatty body (corpus adiposum infrapatellare) and the lateral joint capsule to be able to achieve complete dislocation and rotation of the patella.

The knee is then flexed to a right angle, allowing clear exposure of the medial and lateral femoral condyles, the intercondylar fossa with both cruciate ligaments, the medial and lateral menisci, and the tibial plateau.

Reduction of the infrapatellar branch of the saphenous nerve. Dissection of the medial patellar retinaculum and quadriceps tendon. The patella and patellar tendon are incised longitudinally to provide more central access to the joint for alloarthroplasty.
1. Tibial tuberosity
2. Patella
3. Vastus medialis
4. Medial longitudinal retinaculum of the patella
5. Medial transverse patellar retinaculum
6. Infrapatellar branch of the saphenous nerve

Isolation of the knee joint capsule under the vastus medialis and quadriceps tendon.
The attachment site of the vastus medialis muscle is marked with threads.
Dissection of the quadriceps tendon in a proximal direction.

2. Quadriceps tendon
3. Articular capsule, synovial membrane
4. Medial superior artery and vein of the knee

Condition after opening the capsule of the knee joint and dislocating the patella laterally, the knee joint is straightened.
1. Patellar surface of the femur

3. Medial condyle of the femur
4. Patella
5. Subpatellar fat pad
6. Articular capsule, synovial membrane
7. Articular capsule, fibrous membrane

Condition after bending the knee joint at a right angle. View from the ventral side. The patella is externally rotated and dislocated.

2. Lateral condyle of the femur
3. Patella
4. Tibia
5. Posterior cruciate ligament
6. Anterior cruciate ligament
7. Patellar ligament
8. Medial meniscus
9. Lateral meniscus
10. Subpatellar fat pad
11. Subpatellar synovial fold
12. Pterygoid fold

G) Expanding access. To expose the pes anserine and the medial part of the joint capsule to the angle of the semimembranosus muscle, the incision is extended from the tibial tuberosity 5 cm distally. A skin incision in the proximal third corresponds to a medial parapatellar approach. After dissecting the subcutaneous layer, the infrapatellar branch of the saphenous nerve is first identified and ligatures are applied. A medial arthrotomy is performed in the usual manner 2 cm medial to the inner edge of the patella through the retinaculum.

Then the layer under the infrapatellar branch is raised, the nerve is raised and the fascia and the insertion of the pes anserine are cut under it. If necessary, the incision can be extended proximally to the quadriceps tendon. The knee joint can be bent 90° when tilting the operating table. In this position, the fascia with the tendons of the superficial pes anserine is conveniently exposed dorsally to obtain a clear exposure of the medial joint capsule. When the superficial pes anserine is detached from the tibia, it is necessary to spare the underlying attachment site of the medial collateral ligament.

If necessary, you can also examine the back of the knee joint from the medial side. The knee joint capsule is opened obliquely behind the posterior internal collateral ligament and a Langenbeck hook is inserted. This incision generally provides a good view of the posterointernal angle of the medial meniscus, the posterior capsule of the knee joint, and the deep portions of the medial ligament. If it is necessary to isolate the attachment of the posterior cruciate ligament to the tibia, then the dissection of the capsule can be extended in the medial direction along the femur, and at the same time part of the medial head of the gastrocnemius muscle is dissected.

This incision should not damage the adductor magnus tendon. The articular nerve of the knee and the branches of the upper middle artery of the knee passing above it are also preserved.

d) Anatomy. The so-called posterointernal articular or semimembranous angle is of particular importance for the function of the knee joint. The posterior aspect of the medial joint capsule is dynamically stabilized by the semimembranosus muscle. This muscle has five attachment points, the direction of traction for them depends on the flexion of the joint: the reflex part under the medial collateral ligament passes to the tibia during flexion and provides stabilization from external rotation. The direct medial attachment to the tibia provides tension to the posterior capsule in extension. The oblique popliteal ligament is a continuation of the semimembranosus tendon into the posterior joint capsule.

Two more fibrous cords go, on the one hand, to the posterior medial collateral ligament (posterior oblique ligament), on the other hand, to the aponeurosis of the popliteus muscle.

Arthrotomies in the posterointernal part of the joint can be performed either anteriorly or posteriorly to the posterior internal collateral ligament. This femorotibial ligament is closely related to the posterointernal angle of the medial meniscus. The posterior horn of the meniscus is stabilized by this ligament. This ligament also receives additional dynamic stabilization from the branches of the semimembranosus tendon.

Extend the incision distally to expose the superficial pes anserine and the medial capsular ligamentous apparatus.
Incision of the quadriceps tendon, medial patellar retinaculum, and superficial pes anserine under the infrapatellar branch.
1. Patella
2. Patellar ligament
3. Tibial tuberosity
4. Medial transverse patellar retinaculum
5. Vastus medialis
6. Superficial crow's feet
7. Medial head of the gastrocnemius muscle
8. Infrapatellar branch of the saphenous nerve

Condition after separation of the superficial crow's foot from the tibia. The posterior portions of the joint capsule were open behind the superior medial collateral ligament. Careful to preserve the superior middle artery of the knee and the articular nerve of the knee.
1. Medial condyle
2. Medial meniscus
3. Patellar ligament
4. Medial retinaculum of the patella
5. Internal collateral ligament of the knee joint
6. Vastus medialis
7. Hamstring muscle
8. Adductor magnus tendon
9. Semimembranosus tendon
10. Superficial crow's feet
11. Medial superior artery and vein of the knee
12. Infrapatellar branch of the saphenous nerve
13. Articular nerve of the knee

Extended opening of the posterointernal portions of the joint capsule by retracting the medial head of the gastrocnemius muscle to expose the posterior cruciate ligament.
1. Medial condyle of the femur
2. Medial meniscus
3. Posterior cruciate ligament of the knee
4. Posterior meniscofemoral ligament
5. Medial retinaculum of the patella
6. External collateral ligament
7. Vastus medialis
8. Gastrocnemius muscle, medial head
9. Abductor major tendon
10. Tendon of the semimembranosus muscle
11. Superficial crow's feet
12. Medial superior artery and vein of the knee
13. Infrapatellar branch of the saphenous nerve
14. Articular nerve of the knee

Anatomy. Medial capsular-ligamentous apparatus of the knee joint.
1. Vastus medialis muscle
2. Adductor magnus tendon
3. Semimembranosus muscle
4. Gastrocnemius muscle, medial head
5. Medial condyle of the femur
6. Medial condyle of the tibia
7. Medial meniscus
8. Superficial crow's feet
9. Posterior medial collateral ligament
10. Medial collateral ligament
11. “Medial capsule ligament”
12. “Cap” of the condyle

e) Suturing the wound. The joint capsule, the medial head of the gastrocnemius muscle and the separated “crow's foot” are sutured with interrupted sutures. It is usually recommended to remove the tourniquet and perform hemostasis before closing the wound.

and) Alternative skin incision. Exposure of the knee joint through a medial parapatellar capsular incision can be combined with a lateral parapatellar skin incision. The lateral parapatellar skin incision is preferable for procedures such as synovectomy, arthroplasty, or ligament repair because it causes less damage to the blood supply and innervation of the skin and subcutaneous layer on the anterior surface of the knee. Pre- and infrapatellar innervation of the skin comes mainly from the medial side. The lateral skin incision can be straight or arcuate, starting 5 cm proximal to the superior lateral pole of the patella to the tibial tuberosity.

For gentle dissection of the medial skin flap, the following is recommended: after dissecting the subcutaneous layer, the underlying fascia is divided along the incision. The medial skin flap is separated subfascially in the medial direction. If you follow this order, then the vessels and nerves of the medial side, which pass mainly outside the fascia, are quite reliably protected. A medial arthrotomy is performed in the usual manner after dividing the patellar retinaculum and quadriceps tendon. From this incision, if necessary, a lateral parapatellar arthrotomy, lateral release, or lateral ligament reconstruction can also be performed.

The lateral parapatellar incision can be straight or arcuate (left knee joint).

After dissection of the fascia, a medial skin flap is removed subfascially.
1. Patella

3. Patellar ligament
4. Fascia

Parapatellar dissection of the extensor apparatus (optional from the medial or lateral side)
1. Patella
2. Quadriceps tendon
3. Patellar ligament

The knee joint is one of the most complex joints in the human body; damage to its medial meniscus causes pain and requires immediate treatment. The patient experiences enormous stress even just while walking, not to mention running and playing sports. Cartilage is needed in the knee joint for shock absorption. It is carried out by the lateral and medial menisci.

Specifics of damage

The knee joint consists of the following elements:

ligaments;
cartilage;
bones.

Injuries in the knee joint are as follows:

sprained or torn ligaments;
fracture of the kneecap;
injury;
meniscal detachment.

Meniscus injuries are a closed type of injury, are very painful and take a long time to heal. They are always characterized by acute pain in the knee, sometimes swelling and hemorrhage. In some cases, the knee begins to “walk” freely. The meniscus can be damaged in the following cases:

while playing sports using the wrong technique;
twisting your ankle while running;
landing unsuccessfully after a jump;
hitting your knee on a stair step;
received a strong blow to the knee.

The most common type of injury is a tear of the medial meniscus of the knee. Since this is the internal meniscus, it is less mobile and the load on it is greater. And also it has almost no blood supply, unlike the external one.

For reference! The menisci have the shape of a horseshoe, so they have a body and two horns, one called the upper, the second - the lower.

A rupture of the anterior horn of the medial meniscus is less dangerous, since after it only the joint is blocked. This blockage can be removed by a doctor with the necessary manual influences. But, unlike the anterior horn, it may be accompanied by a knee popping out.

Damage to the medial meniscus can be divided according to the type of tear:

Horizontal rupture is often associated with neoplasms.
Vertical, also called a “watering can handle” tear of the medial meniscus.
A transverse tear, this type of tear heals the easiest.
A flap tear most often requires surgery.
And the one that can combine several is combined.

Damage is divided into degrees:

Grade 1 is minor damage;
Grade 2 is more serious damage;
3rd degree is a gap.

It is very important not to delay visiting a doctor and treatment after damage to the medial meniscus of the knee joint.

Important! The longer the patient delays treatment, the further degenerative changes in the meniscus of the knee joint can progress.

How is the treatment carried out?

Directly with an injury, you need to go to the emergency room and see a traumatologist. If quite a long time has passed since the injury, two weeks or even more, and there is a suspicion of a chronic stage, then you need to consult a therapist. He examines the patient, prescribes tests and diagnostics. Depending on the specifics of the equipment, diagnostics are carried out using the following studies:

magnetic resonance;
ultrasonic;
radiographic;
tomographic.

Based on the research results, the therapist will make a primary diagnosis. It will help eliminate pain and relieve swelling. And then, if it is a minor injury, he will prescribe conservative treatment:

physiotherapy;
medicines;
physical therapy;
peace;
diet.

Sometimes, for example, with instability of the medial patellar retinaculum, a firm fixation of the knee is required.

Medication assistance

During this type of treatment, medications are prescribed in both tablet and ointment form. It could be:

Diclofenac;
Nimesulide;
Ibuprofen.

About damage to the posterior horn of the 2nd degree.

At the first stage, the drugs should:

relieve swelling;
remove inflammation;
numb.

At the recovery stage, chondroprotectors are prescribed, which can be used either in tablets or administered by injection. Hyaluronic acid injections are increasingly being used; they are good for the rapid regeneration of cartilage tissue.

Physiotherapy

Represents the effects of heat, dirt or radiation on a sore spot. They increase blood flow, thereby accelerating tissue regeneration. Types of physiotherapy:

electrophoresis;
Ultrasound treatment;
mud baths;
paraffin wraps.

The type of treatment is selected by the doctor individually. If it does not produce results, or the case is more serious, the therapist will refer you to a specialist:

see an orthopedic traumatologist if this is an advanced injury;
see an arthrologist if these are inflammatory diseases of the joints;
see an infectious disease specialist if the disease is bacterial.

Each of the specialist doctors may prescribe an additional examination, depending on the suspicion of a particular disease.

Important! Physiotherapy begins only after inflammation, swelling and pain are relieved. Overheating during physical therapy will only make the inflammation worse.

Arthroscopy.

After examination and diagnosis, the doctor decides to treat the knee or refer it for surgery. During the operation the following actions can be performed:

Cut off the damaged part of the meniscus. It is very important that the edges of the meniscus are smooth; if this requires cutting off a part, then this is done.
Restore the meniscus. Damaged tissues are stitched together, this is only done if you immediately consult a doctor after receiving an injury. Otherwise, tissue necrosis may occur, and fusion will become impossible.
Remove the meniscus. This is the most extreme case, since removal of the meniscus is accompanied by unpleasant consequences.
Replacement of the meniscus with a prosthesis or donor organ.

Nowadays the operation is mainly done using arthroscopy. Its advantages over the old method are as follows:

a small area of skin is incised;
shorter recovery time;
there is no need to fix the joint;
It is possible to monitor the progress of the operation using a high-precision camera.

After the operation, the doctor will monitor the patient for a long time. Since the recovery period will be long, additional stimulation may be required in the form of physiotherapy, chondroprotectors and physical therapy. After surgery, the patient is often transferred to a day hospital.

Manual therapy

This therapy is based on the study of the musculoskeletal system and blood flow. The course of treatment is very similar to massage. Osteopaths claim that during their manipulations they direct flows in the right direction, and the body begins to work correctly.
Since increased blood flow helps with some meniscal injuries, osteopaths can help in some way. But it is worth remembering that osteopathy is not recognized by official medicine.

Traditional methods of treatment

Traditional medicine has also prepared its own recipes. The following is offered:

Make lotions from a mixture of honey and alcohol in equal proportions.
Make compresses from onion pulp.
Rinse your knees with a decoction of nettles and violet leaves.
Apply a burdock leaf to the sore knee.

Of course, these methods are not so strong for a meniscus tear, but they can still help relieve pain and relieve swelling. It is necessary to consult with your doctor about the advisability of combining it with traditional treatment. Sometimes doctors are not against it, but perceive traditional medicine as a useful addition.

The ACL is more likely than other knee ligaments to rupture.

Complete or partial ruptures of the ligament itself occur in 90% of cases on the proximal (femoral) side. Most of them are initially interstitial. Less commonly observed are separations of the ligament with a bone fragment from its attachment site on the tibia (avulsion fractures). The latter usually occur in young patients.

Acute ACL rupture:

clearly interrupted or becomes serpentine,
its anterior contour becomes roughly concave.

Indirect signs of an ACL rupture:

heterogeneity or absence of the ligament in its anatomical position in the sagittal projection in the intercondylar fossa,
wavy or discontinuous contour of the ligament,
displacement of the tibial and femoral parts of the ligament makes it possible to detect its rupture,
increased curvature of the PCL.

Small tears may not change the contours of the ACL, but lead to blurring of its bundles. More severe tears change both the shape and course of the ligament, causing it to sag posteriorly.

With a complete rupture, the ligament may lie horizontally in the intercondylar fossa. However, a complete rupture may be compatible with its normal position, manifested only by a complete break of high-signal fibers due to edema and hemorrhage at the site of the break.

The classic presentation in cases of avulsion with a bone or cartilaginous fragment is a tense joint effusion with macroscopically visible fat on T1WI.

Old incomplete ruptures of the ACL can cause loss of static. Diffuse inhomogeneous moderate signal enhancement in T1 WI is possible. The ligament may have unclear edges or may not be defined. Sometimes, when a rupture occurs a long time ago, the ligament may look normal due to scarring. With an old rupture, the ligament may not be detected arthroscopically at all. An old ACL rupture is often manifested by its complete absence during an MRI examination; it is not detected in the lateral part of the intercondylar fossa.

Posterior cruciate ligament (PCL) injuries

PCL ruptures are found much less frequently than ACL ruptures.

The PCL is very strong; complete ruptures, as well as ruptures at the level of attachment to the tibia or femur along with bone fragments, are rare. In most cases, the ruptures are incomplete and occur in the middle part of the ligament. Other cases involve the attachment to the tibia, where avulsion fractures may occur.

Mechanism

a consequence of the impact of a force directed from behind on the knee joint, which leads to posterior displacement of the tibia - hyperextension injuries.

PCL ruptures can be isolated, but are more often associated with other serious joint injuries, including rupture of the posterolateral portion of the capsule and rupture of the arcuate ligament complex.

Morphology

Local expansion of the ligament is often noted, but tears do not resemble a pathological mass as much as ACL tears. If the rupture is complete, a gap may be found separating the ligament. When a ligament ruptures, it may have a humped or S-shaped appearance.

In subacute ruptures, foci characteristic of hemorrhages may be detected. In old scarred ruptures, the signal is little changed and only slight changes in contour or displacement of the tibia may be visible. The defining sign may be a decrease in the intensity of the MR signal from the subchondral layer of the tibia due to trabecular edema.

Injury to the medial collateral ligament

Due to the normal valgus position of the knee, the internal collateral ligament is more susceptible to injury than the external collateral ligament.

Injuries to the medial collateral ligament are divided into three clinical grades:

I - rupture of a small number of deep capsular fibers (stretching). The ligament appears normal in thickness and outline on MRI. The MR signal inside the ligament is increased due to edema in T2WI, but fluid may also envelop the ligament.
II - rupture of up to 50% of the fibers (incomplete), the altered MR signal extends to the surface of the ligament. Grade II injuries have features of both grades I and III and are less accurately characterized by MRI.
III - complete break. With degree III damage, there is a complete rupture of the deep capsular and superficial fibers. It manifests itself as a break in the ligament, which has the appearance of a dark stripe with thickening of its proximal and distal sections and serpentine-like convoluted contours. T2WI can accurately localize the location of the rupture.

The ligament may separate from its attachment to the femur or tibia. In this case, hemorrhage and swelling are found medial to the ligament.

Complete ruptures of the medial collateral ligament are most often accompanied by bone contusions and trabecular microfractures of the femur and tibia. ACL tears are also often associated with medial collateral ligament tears and bone injuries.

Injuries to the lateral collateral ligament

Damage to the lateral structures is found less frequently than to the medial ones. Usually occur with severe trauma with varus impact. A rupture of the lateral collateral ligament is manifested by a complete absence or interruption of the contours. The ligament has a wavy appearance or local accumulations of fluid. A capsular tear can be detected by the accumulation of fluid in the surrounding soft tissue, usually lateral to the joint in the area of the hamstring muscle and tendon.

Damage to the patellar ligament

Patellar tendinitis usually develops in the area where the ligament connects to the patella. Tendinitis occurs as a result of chronic exercise and is common among runners.

Damage to the quadriceps tendons and patellar ligament, in addition to trauma and chronic overload, can be a secondary lesion in systemic diseases (hyperparathyroidism, gout, rheumatic diseases).

The following changes are characteristic of patellar tendonitis:

Thickening of more than 7 mm of the ligament at the level of the lower edge of the patella; - increased intensity of the MR signal during any pulse sequence, most often localized in the anterior part of the proximal ligament; - unclear edges especially behind the thickened area; - increase in the intensity of the MR signal from the fat pad on T1VI; - the same intensity of the MR signal on T2WI and T1WI with contrast in combination with Hoffa’s disease.

Complete rupture of the patellar tendon accompanied by a tortuous course of residual distal fibers and a high location of the patella. The patellar ligament can also have a tortuous appearance in the presence of effusion in the anterior inversion of the joint and in case of a rupture of the ACL, since the tibia, when displaced anteriorly, changes the angle of origin of the tibial tuberosity ligament, and the distance between the tuberosity and the patella also changes.

Distal patellar tendinitis noted in aseptic necrosis of the tibial tuberosity (Osgood-Schlatter disease). MRI reveals thickening of the distal ligament with blurred contours, having an increased MR signal on T2WI and with suppression of the MR signal from fat.

Damage to the patellar retinaculum

Almost always there is a complete or partial rupture of the internal retinaculum of the patella.

Signs:

swelling of the patellar retinaculum,
extension of the patellar retinaculum,
subluxation of the patella.

Literature

"ATLAS MAGNETIC RESONANCE DIAGNOSTICS OF KNEE JOINT DAMAGES" V.V. Churayants, O.P. Filippov, Moscow 2006.

The patella is a bony structure that takes part in the formation of the knee joint. It is located anterior to the articular surfaces of the thigh and lower leg and is held in place by a ligamentous apparatus formed by strong connective tissue cords.

If there is excessive impact on the joint in the area of the kneecap (excessive flexion or extension of the knee, rotation of the hip with a fixed shin, direct mechanical shock), a mechanical violation of the anatomical integrity of the bone, cartilaginous base of the patella or ligamentous structures occurs. This leads to a significant disruption of the functional activity of the structures, as well as the development of an inflammatory reaction in the tissues, aggravating the clinical symptoms of the injury.

Causes

Violation of the anatomical integrity of the cartilaginous and bone parts of the cup, as well as the ligamentous apparatus, occurs due to the influence of various causative factors. Of these, the most common are:

Road traffic accidents.
Domestic injuries.
Industrial injuries.
Sports injuries.

The mechanism of development of a violation of the anatomical integrity of the knee has certain similarities, regardless of the reason that led to its implementation.

Classification

Depending on the nature and location of injuries to the patella and its structures, they are divided into several main types. Depending on the nature of the injury, there are:

A fracture of the bone base, which can be with or without displacement of bone fragments. A comminuted fracture with the formation of several bone fragments is distinguished separately.
A dislocation of the kneecap, which is usually accompanied by a torn ligament.
Sprain and damage to the patellar ligament.

A common injury is injury to the patellar retinaculum (the main ligament that stabilizes the bony base of the kneecap). In this case, the medial suspensory ligament of the patella is predominantly injured. Damage to the structures of the ligamentous apparatus can be isolated or combined with other injuries (fracture or dislocation).

Thus, damage to the medial retinaculum of the patella is accompanied by dislocation and damage to the cartilaginous structures, the internal meniscus of the knee, collateral ligament and tendons of the femoral muscles are injured. Injury to cartilage structures is called osteochondral damage to the patella and is usually a consequence of degenerative pathological processes in cartilage tissue (osteoarthrosis).

Symptoms

Clinical symptoms of patella injury include several characteristic manifestations, which include:

Pain in the anterior surface of the knee in the area of the patella, which is usually of high intensity and intensifies when attempting to move.
The appearance of clicks and crunching, which accompanies damage to the cartilage of the patella, in particular against the background of chondromalacia (destruction of cartilage tissue against the background of a degenerative-dystrophic process).
Pathological mobility of the kneecap, which indicates that the medial patellar ligament is injured. Damage to the lateral (side) ligament of the knee can cause the lower leg to deviate to the side.
Restricted knee mobility.
Swelling of soft tissues, redness (hyperemia) of the skin, which are a sign of the development of an inflammatory reaction.

Symptoms are accompanied by impaired functional activity of the knee with limitation of active and passive movements in it.

Diagnostics

Damage to the patella of the knee joint is diagnosed using techniques for visualizing its structures. These include:

radiography;
computed tomography or magnetic resonance imaging;
arthroscopy.

The most informative, but invasive procedure is arthroscopy. It involves inserting a tube with lighting and a camera into the cavity of the knee joint. This technique is often performed for therapeutic purposes.

Treatment

Conservative therapy is possible for minor injuries without disturbing the anatomical relationship of the knee structures. It is used if partial damage to the medial patellar retinaculum, as well as other knee ligaments, has been diagnosed and includes the use of anti-inflammatory drugs, chondroprotectors and physiotherapy.

In other cases, surgical treatment is used, including restoration of integrity and anatomical relationship using open access or arthroscopy.

Lateral patellar hyperpressure syndrome (LPHS) is a fairly common pathology of the patellofemoral joint (PFJ), occurring mainly among children and adolescents. SLGN is the cause of 7 to 15% of all visits for orthopedic pathology of the knee joint.

SLGN develops when the normal congruent relationship between the articular surfaces of the femoral and patella condyles is disrupted, as well as when the balance between the medial and lateral stabilizers of the patella is disturbed, and is characterized by a redistribution of specific pressure over different areas of the articular surfaces of the knee joint, which leads to overload of its lateral parts.

There are two groups of reasons for the development of SGLN. In most cases, these are anomalies of the development of the knee joint (congenital deformities of the patella, hypoplasia of the lateral femoral condyle, highly located patella - patella alta, lateral tibial tuberosity, increased density of the lateral retinaculum of the patella and other anomalies leading to lateroposition of the patella). It is also possible for the syndrome to develop after traumatic injuries to a normally formed joint, which result in fibrosclerotic changes in the damaged muscles and ligaments, stretching of the medial retinaculum of the patella, the joint capsule, which is not compensated during the healing process and leads to outward displacement of the patella.

In accordance with modern ideas about the anatomy of the patellofemoral joint, there are 5 articular surfaces on the patella, although 2 main ones are clinically important - the medial and lateral, separated by a central longitudinal ridge. Wiberg described 3 types of patellar configurations.

In type I, the medial and lateral articular surfaces of the patella are equal in area; in types II and III, a progressive decrease in the proportion of the medial articular surface is observed. In this case, the dominant lateral articular surface bears the bulk of the load exerted by the quadriceps, which leads to SLGN. In addition, the development of SLHN is facilitated by the asymmetry of the shape of the trochlea of the articular end of the femur, while the lateral condyle is small and the pressure exerted on the osteochondral structures of the patellofemoral joint is significantly higher than that normally.

In addition to the osteochondral structures, the musculo-ligamentous apparatus of the knee joint, presented by Warren and Marshall as a three-layer system medially and a two-layer system laterally, plays a role in the genesis of SLGN. The medial patellofemoral ligament (MPFL), located under the medial head of the quadriceps femoris muscle, is the main static stabilizer of the patella, playing the role of keeping the patellofemoral joint from lateral displacement. At the same time, the quadriceps femoris muscle is the main dynamic stabilizer of the patella, and the most important role in the resistance of the medial head of the quadriceps to the lateral displacement of the patella is played by its oblique fibers, oriented relative to the long axis of the quadriceps tendon. Koskinen and Kujala showed that in patients with LGN and lateroposition of the patella, the attachment area of the medial head of the quadriceps is located more proximally than normal, which does not allow the muscle to realize a dynamic stabilizing function.

The lateral retinaculum of the patella has superficial and deep components. The deep component attaches directly to the patella and is the first line of resistance to patellar displacement on the lateral side of the joint. It is represented by the transverse fascia, which fixes the iliotibial ligament to the patella. When the knee is flexed, the iliotibial ligament moves posteriorly, resulting in increased lateral tension on the patella. If the patient has weakened medial stabilizers, tilting of the patella relative to the frontal plane may occur with an increase in the load on its lateral facet and the development of LGN.

Pathogenesis

The pathogenesis of the progression of SLGN can be represented as follows: as a result of overload of the lateral sections of the PFJ, the level of tension in the osteochondral and soft tissue elements of the joint increases, which leads to the development of chondromalacia, asymmetric wear of the joint with the development of dystrophic changes in the osteochondral structures. Then, dystrophic disorders are replaced by the stage of cartilage degeneration, its destruction, which ultimately leads to the formation of deforming arthrosis of the patellofemoral joint.

Clinical manifestations and complications

The main clinical manifestation of SLGN is constant aching pain in the anterior part of the knee joint (increased with flexion), caused by secondary chondromalacia, as well as irritation of the nerve fibers located directly in the lateral retinaculum of the patella. There is swelling of the joint, recurrent synovitis, and crunching when moving. As hyperpressure progresses, a feeling of instability, joint laxity, and painful pseudo-blocking of the joint may appear.

Complications of SLHN can include chondral and osteochondral fractures of the lateral femoral condyle, medial and lateral facets of the patella; with a long-term course with traumatic episodes, habitual dislocations of the patella can be observed. To prevent complications in patients with LGN, it is necessary to pay special attention to a thorough examination of patients in order to early identify signs of this pathology. In diagnosing SPHN, careful collection of anamnesis of the disease, assessment of pain syndrome and the results of special clinical tests are important. From the point of view of determining the etiology of the disease and choosing a treatment method, it is important to conduct a test for limiting the elevation of the lateral edge of the patella: for example, the inability to raise to a neutral position of 0° indicates a tight lateral retinaculum of the patella. Also important in the diagnosis of SLGN is the measurement of the Q angle, or the quadriceps angle formed between the lines, one of which is drawn from the superior anterior iliac spine to the patella, the other from the center of the patella to the tibial tubercle. Values of this angle exceeding 20° must be regarded as pathology.

X-ray examination, CT, MRI, myography m. quadriceps femoris (detection of dysfunction of the lateral and medial heads of the muscle) and diagnostic arthroscopy make it possible to verify the diagnosis.

Treatment

Treatment of SLGN can be conservative and surgical. Conservative therapy consists of active exercises, massage, and wearing braces on the knee joint. The measures are aimed at increasing the tone of the medial head of the quadriceps and stretching the lateral retinaculum of the patella. Conservative treatment is long-term and requires significant effort on the part of the patient, but can be effective in 75% of cases.

Among the open techniques, of which, according to Marion and Barcat, there were already about 100 in 1950, the most common are modifications of operations according to Roux (Fig. 3, A: moving tuberositas tibiae inward), according to Krogius (Fig. 3, B: with on the outer side of the joint, parallel to the patella, a capsule incision about 15 cm long is made; on the inner side, two more parallel incisions are made at a distance of 3 cm from one another, which form a strip attached below to the tuberositas tibiae, and on top covering part of the fibers of the m. vastus tibialis; patella they are pulled inwards, while the external gap opens, which is filled with a strip of the joint capsule thrown over the patella from the medial side), according to Friedland (mobilization of the rectus femoris muscle along with the patellar ligament, their movement in the medial direction with fixation to the sartorius, adductor magnus and medial tendons broad muscle of the thigh and suturing the articular capsule from the medial side into a longitudinal fold). However, when using these techniques, a wide skin incision, long-term postoperative immobilization and long-term rehabilitation of the limb are required.

Complications such as secondary osteoarthritis, progression of retropatellar arthrosis with the development of medial hyperpression, fatigue fractures of the tibia as a result of graft insertion, neuritis, bursitis, secondary chondromalacia, etc. are possible.

In 1972, Chen and Ramanathan proposed the following method for the treatment of LGN: after preliminary diagnostic arthroscopy, through the existing arthroscopic approaches (inferior and, if necessary, superolateral) they release (i.e. dissect) the lateral portion of the extensor apparatus from inside the knee joint (using an electrocautery knife or Smillie knife). This technique is characterized by significant effectiveness and safety: the incidence of complications is less than 10%. In 1995, Henry and Pflum supplemented this technique with arthroscopic suturing of the medial retinaculum using a special instrument, thereby creating its fold (reefing).

A combination of arthroscopic release and open reefing is often used - the so-called. semiarthroscopic surgery. Today, given the high diagnostic significance of arthroscopy, even in cases where open intervention is planned, it is advisable to preliminarily conduct an arthroscopic assessment of the cartilaginous surfaces of the knee joint in order to visually determine intra-articular pathological changes and determine further treatment tactics.

Separately, it is necessary to note cases of traumatic injuries to the patellofemoral joint area against the background of LGN. In most cases, they lead to an osteochondral fracture of the lateral or medial facet of the patella or the lateral femoral condyle, and the large osteochondral fragment separated as a result of such damage leads to blockade of the joint and the development of severe pain. The main purpose of the operations performed in such cases is to remove the free fragment of the patella from the articular cavity and restore joint function. To restore normal biomechanical relationships in the knee joint, eliminate lateral hyperpression syndrome and remove the affected part of the patella from increased load, in some cases we supplement such intervention with minimally invasive lateral release of the extensor apparatus. This leads to improved congruence in the knee joint and simultaneous decompression of damaged structures, thus facilitating healing of the wound surface.

Thus, when performing diagnostic arthroscopy and detecting a large osteochondral fragment of the patellar facet, the dimensions of which do not allow its removal from the joint cavity through arthroscopic punctures, a superolateral microarthrotomy up to 2 cm in size is performed. The osteochondral fragment is removed through this hole. The surgeon inspects the patellar facet and lateral femoral condyle to assess the condition of the wound surface and, if necessary, performs arthroscopic abrasive chondroplasty. Then, having lifted the skin proximal from the microarthrotomy access from the wound, the surgeon, using a scalpel, under the control of a finger inserted into the cavity of the joint, dissects the lateral retinaculum of the patella over 1-2 cm, drawing the incision line as close as possible to the edge of the patella and, at the same time, being careful not to cut the lateral head of the quadriceps muscle. Then the surgeon repeats the procedure in the distal direction for 3-5 cm. As a result, decompression of the damaged structures of the patellofemoral joint is achieved.

Thus, the proposed method of surgical treatment of osteochondral fractures of the medial facet of the patella against the background of lateral hyperpression syndrome makes it possible to improve the anatomical relationships in the knee joint with simultaneous decompression of the damaged surface of the patella, which leads to the restoration of conditions for normal biomechanical functioning of the knee joint and accelerated healing of the defect of the articular surface of the patella .

According to Crosby and Insall, 7% of patients who underwent open surgery for correction of LPHN have excellent results, and 52% have good results.

A similar study was conducted by Chen and Ramanathan (1984) among patients who underwent arthroscopic intervention for LPH (on average 6 years after surgery): the results were slightly better: 59% - excellent, 27% - good.

The figure shows an example of successful surgical treatment of SLGN using a traditional technique: a patient with symmetrical pathology of both knee joints underwent Roux surgery on one joint, the other was treated conservatively. 9 years after the operation, the result on the operated joint is excellent, on the other joint it is satisfactory.

Since 1984, on the basis of the children's traumatology and orthopedic department of the 6th City Clinical Hospital in Minsk, 24 operations were performed on 23 patients with LGN, 3 of which were arthroscopic operations (releasing the lateral portion of the extensors). The main reason for admission of patients with LGN to the hospital was spontaneous or post-traumatic dislocation of the patella against the background of long-term pain in the anterior part of the knee joint. During intraoperative examination of the patellar facets, degenerative changes in the articular cartilage were discovered, and in 3 cases, osteochondral fractures of the patella.

The average age of the operated patients was 13.5 (range 5 to 25) years. There were 13 girls (56.5%) and 10 boys (43.5%) among the patients. The average length of stay of patients in hospital for traditional interventions was 22.4 (up to 46) days, for interventions using arthroscopic access - 14 (up to 22) days. Moreover, patients who underwent arthroscopic surgery were allowed to put full load on the operated limb already on the 7th postoperative day, while after open interventions it was possible to load the limb only by the end of the 2nd postoperative week. Long-term postoperative results (from 1 month to 20 years, on average 9 years) were monitored in 12 patients (9 of them underwent open surgery, 3 arthroscopic).

The use of modern minimally invasive techniques, characterized by relatively short periods of postoperative immobilization, rehabilitation, and patient stay in the hospital, makes it possible to achieve high efficiency of treatment and reduce the incidence of postoperative complications and secondary arthrosis of the patellofemoral joint.

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Knee joint (normal anatomy in axial projection)

1. Quadriceps tendon 2. Vastus medialis 3. Femur 4. Vastus lateralis 5. Sartorius 6. Tibial nerve 7. Biceps femoris 8. Gracilis 9. Semimembranosus 10. Semitendinosus 11. Lateral head gastrocnemius muscle 12. Medial head of the gastrocnemius muscle 13. Common peroneal nerve 14. Medial patellar retinaculum 15. Lateral patellar retinaculum 16. Patella 17. Medial collateral ligament 18. Patellar cartilage 19. Fibular collateral ligament 20. Anterior cruciate ligament 21. Su popliteus tendon 22. Posterior cruciate ligament 23. Iliotibial tract 24. Lateral meniscus 25. Patellar tendon 26. Medial meniscus 27. Anterior ligament of the fibular head 28. Popliteus muscle 29. Tibial tuberosity 30. Tibialis anterior muscle

Patella dislocation

Smetanin Sergei Mikhailovich

traumatologist - orthopedist, candidate of medical sciences

Moscow, st. Bolshaya Pirogovskaya, 6., bldg. 1, metro station Sportivnaya

In 2007 he graduated with honors from the Northern State Medical University in Arkhangelsk.

From 2007 to 2009, he completed clinical residency and correspondence postgraduate studies at the Department of Traumatology, Orthopedics and Military Surgery of the Yaroslavl State Medical Academy on the basis of the Emergency Hospital named after. N.V. Solovyova.

In 2010, he defended his dissertation for the degree of Candidate of Medical Sciences on the topic “Therapeutic immobilization of open fractures of the femur.” Scientific supervisor, professor V.V. Klyuchevsky.

From 2010 to 2011 he worked as a traumatologist-orthopedist at the Federal State Institution “2 Central Military Clinical Hospital named after. P.V. Mandryka."

Since 2011, he has been working in the clinic of traumatology, orthopedics and joint pathology of the First Moscow State Medical University. THEM. Sechenov.

2012 – training course on knee replacement, prof. Dr. Henrik Schroeder-Boersch (Germany), Kuropatkin G.V. (Samara), Yekaterinburg.

February 18, 2014 – workshop on orthopedic surgery “Knee and hip joint replacement”, Dr. Patrick Mouret, Klinikum Frankfurt Hoechst, Germany.

November 28-29, 2014 - training course on knee replacement. Professor Kornilov N.N. (RNIITO named after R.R. Vreden, St. Petersburg), Kuropatkin G.V., Sedova O.N. (Samara), Kaminsky A.V. (Kurgan). Topic: “Course on ligament balance during primary knee replacement,” Morphological Center, Yekaterinburg.

Associate member of the International Society of Orthopedic Surgery and Traumatology (SICOT - French Société Internationale de Chirurgie Orthopédique et de Traumatology gie; English - International Society of Orthopedic Surgery and Traumatology). The society was founded in 1929.

Scientific and practical interests: endoprosthetics of large joints, arthroscopy of large joints.

Anatomy of the patella

The patella is the largest sesamoid bone.

The sesamoid bone is usually located in the thickness of the tendons and serves to increase the traction of the muscle. Attached to the inferior pole of the patella is the patellar ligament, which runs to the tibial tuberosity. The quadriceps femoris muscle is attached to the superior pole of the patella. The patella is involved in the extension of the lower leg. Patella retinaculums are attached to the inner and outer surfaces of the patella, which help keep the patella centered during movement. When extended, the patella is free in the cavity of the knee joint, and when flexed, it fits tightly to a special groove on the femur - the femoral patella joint is formed. The surface of the patella, which slides along the femur, is an articular surface, covered with thick cartilage.

Two surfaces of the patella - on the right is the articular surface

Patellar instability. Patellar instability is a condition in which the patella tends to move from a central position to the side.

Above - lateral radiograph, below - axial, which shows the normal relationship of the patella and femur

There is hyperpression of the patella, that is, increased pressure on the articular facet - lateral hyperpression, that is, increased pressure on the external condyle of the femur, medial hyperpression, that is, increased pressure on the internal condyle of the femur. With lateral hyperpression, the patella presses on the outer facet; with even greater displacement, subluxation of the patella appears; with complete displacement, dislocation occurs.

On the left - subluxation of the patella, tendency to shift outward; on the right - dislocation of the patella

Causes of luxating kneecap

Weakness of the internal retinaculum ligament, weakness of the thigh muscle, dysplasia of the femoral condyles, high position of the patella, weakness or overstrain of the patellar retinaculum and others.

The anatomical features of the femoral condyles play a key role in the stability of the patella. There is dysplasia of the lateral condyle, and the patella moves outward more easily; dysplasia of the internal condyle, in which it is easier for the patella to move medially.

Condylar dysplasia is clearly visible on axial x-rays or MRI studies.

Symptoms of a luxated patella

Symptoms of patellar luxation are pain in the anterior part of the knee joint, a feeling of instability of the kneecap, a painful click when moving the knee joint - this occurs when the new positioning of the patella is incorrect.

Schematic displacement of the patella outwards

One of the causes of patellar luxation is damage to the internal retinaculum of the patella.

Synovitis is excessive accumulation of fluid in the knee joint. During the examination, the doctor interviews the patient to examine the leg. To determine the inclination of the patella, the doctor performs special tests - when pressing outward on the patella, the pain may increase; increased pain when pressing on the patellar retinaculum.

Examination of a leg with suspected patellar instability

Patellar dislocation outwards

Diagnosis of patellar dislocation

To clarify the diagnosis, X-rays, magnetic resonance imaging or computed tomography are performed. X-rays are taken in direct, lateral, axial projections - at an angle of 20 degrees or 45 degrees of flexion. Computed tomography allows you to more accurately determine the displacement of the patella. In addition, computed tomography can determine the position of the tibial tuberosity. The most important indicator will be the TT - TG index. This is the distance between the tibial tuberosity and the groove of the femur in the axial projection - a distance of more than 15 mm indicates in most cases a subluxation of the patella.

Treatment of kneecap dislocations

Treatment of patellar dislocation can be conservative or surgical. Conservative treatment includes physical exercises, taping and the use of special orthoses.

Surgery for dislocated patella

As a rule, for pain in the anterior part of the knee joint, arthroscopy of the knee joint is performed, which evaluates the position of the patella, the condition of the bone cartilage, and the integrity of the menisci and ligaments. If there is only lateral hyperpression, then arthroscopic mobilization of the external parts is performed - the external suspensory ligament is dissected.

If the patellar retinaculum is damaged, an operation is performed to strengthen it. One of the options for retinaculum repair is the Medial Patellofemoral Ligament (MPFL) operation. The essence of the operation is to replace the torn patellar retinaculum using a graft from the patient's tendon and fix it to the patella and femur at the point when, when bending the knee joint, the grafts are evenly tensioned.

Schematically shows the fixation of the graft to the patella and femur using anchor fixators (MPFL)

Reconstruction scheme (MPFL)

Knee brace

In the postoperative period, the leg is fixed in an orthosis, and the patient gradually develops movements and rehabilitation. Return to sports is possible after 6 months.

Treatment of patellar dislocation of the knee joint in Germany

Our expert:

Dr. Peter Angele

Professor. M.D. President of the AGA Society (Europe's largest arthroscopic society of surgeons).

Sports orthopedist, surgeon Official Commissioner of FIFA. Head of the FIFA clinic. Specialist in knee cartilage transplantation. Instructor of the European Association of Arthroscopy and Joint Surgery (AGA). Performs minimally invasive interventions per year.

A fairly common problem in the anterior knee joint is acute dislocation of the patella. We refer to lateral, or external, acute patellar luxation because medial, or internal, patellar luxation is vanishingly rare. The increasing incidence of primary patellar dislocations is associated, first of all, with an increase in participation in active sports associated with a sharp change in the direction of movement.

Patients with primary or acute patellar dislocation are usually young with an active lifestyle.

Patella injury: symptoms and causes

Anatomically, the patella tends to move outward when the knee joint moves. The higher the force directed at flexion or extension of the knee joint, the more the patella moves outward. This displacement is resisted by two anatomical structures: the trochlea of the femur and the medial (internal) retinaculum of the patella. If the force displacing the patella outward exceeds the elasticity of the medial (internal) retinaculum, this retinaculum ruptures with dislocation of the patella, which is accompanied by acute pain, a feeling that “something has shifted and snapped into place” in the knee joint and increased swelling. In such a situation, you should immediately contact an orthopedic traumatologist to clarify the diagnosis and decide on further treatment tactics.

To correctly diagnose primary dislocation of the patella of the knee joint in Germany, a competent orthopedic traumatologist, after a clinical examination and careful questioning of the patient about the mechanism of injury, will take radiographs of the knee joint and recommend an MRI examination of the knee joint. In the event that the patella, having dislocated, does not return to place, an orthopedic traumatologist will eliminate the dislocation during examination. After performing an MRI of the knee joint, the orthopedic traumatologist will determine the final treatment tactics. It is very important to correctly diagnose this injury to the knee joint due to the fact that acute dislocation of the patella in its clinical picture and mechanism of injury is very similar to a rupture of the anterior cruciate ligament.

Treatment of injuries to the patella of the knee joint

Most often, with primary dislocation of the patella, if there is no damage to other structures of the knee joint except the medial retinaculum of the patella, a positive result is achieved by conservative treatment, which consists of immobilizing the knee joint in a comfortable straight orthosis for 3 weeks from the moment of injury. If there is a large accumulation of blood in the cavity of the knee joint (inevitable, unfortunately, in the case of acute injuries), a competent orthopedic traumatologist will perform a puncture of the knee joint with strict adherence to asepsis and antisepsis. Particular attention should be paid to the problems of preventing thrombosis: a competent orthopedic traumatologist will recommend compression stockings and special medications to reduce the likelihood of thrombosis. After the proposed period of immobilization and follow-up examination in case of acute dislocation of the patella, the patient is recommended a course of rehabilitation treatment with physical therapy, careful development of movements of the knee joint under the supervision of rehabilitation doctors. If the patient does not have anatomical prerequisites for re-dislocation of the patella, then the percentage of successful return to previous sports activities and active lifestyle is high even without surgical treatment.

In the case when, in addition to the medial retinaculum of the patella, during acute dislocation of the patella, for example, articular cartilage is damaged with the formation of free chondral bodies, the patient is recommended to undergo an arthroscopic revision of the knee joint to remove them, followed by conservative treatment of acute primary dislocation of the patella. It is very important to trust a competent orthopedic traumatologist with extensive experience and knowledge, because incorrectly chosen treatment tactics can lead to the formation of chronic instability of the patella, which manifests itself in its constant dislocations and destruction of articular cartilage.

If an orthopedic traumatologist, after analyzing clinical data and the results of objective studies, assumes that the success of conservative treatment will be low, then he will recommend primary surgical restoration of the medial patellar retinaculum or, as it is also called, the medial femoropatellar ligament of the knee joint. The basis for the initial recommendation of surgical treatment may be the low profile of the femoral trochlea (hypoplasia of the femoral condyle), which anatomically prevents its outward displacement. Among plastic and flexible young patients with soft connective tissue, the incidence of recurrent patellar dislocation after primary acute patellar dislocation is unfortunately also high, and primary repair of the medial femoropatellar ligament is recommended for them.

Surgical treatment for patellar fracture

Depending on the type of injury or rupture of the medial femoral-patellar ligament, the orthopedic traumatologist will recommend one type of surgical treatment or another. Surgical treatment may involve either attempting to suture the damaged medial patellar retinaculum or repairing the femoropatellar ligament with an autograft from one of the patient's own tendons. This ensures the best graft survival and the absence of allergic reactions while restoring the normal anatomy of the anterior knee joint. Performing surgical treatment avoids long-term immobilization of the knee joint. Full load on the operated knee joint, as a rule, is allowed from the earliest half-operative period. After such an operation, careful rehabilitation treatment is required under the supervision of an experienced doctor of rehabilitation medicine.

The decision regarding the choice of one or another treatment tactics should be made and recommended by a competent and experienced orthopedic traumatologist, because only in this case the patient will be able to return to previous sports activities and reach new heights as soon as possible after the injury. And conservative. and surgical treatment have a right to exist, the choice should be made after a thorough analysis of each case of acute patellar dislocation in Germany with a comprehensive full examination.

Medial patellar retinaculum

The patellas, also called kneecaps, are small, round, flat bones. They are located on the front of the knee joints. Tendons that extend to the quadriceps femoral muscles are attached to them. These are the largest sesamoid bones. The functional significance of this element is difficult to underestimate. The junction of the patella and femur is called the patellofemoral joint. It is this that carries out the operation of sliding the patella when a person moves.

The patella is located in a depression where it can be held in place by ligaments and tendons coming from the quadriceps muscle. Mobility is limited by the femoral condyle. The kneecaps protect the joints from a variety of external influences.

The injury may be acquired or congenital. The duration of the injury allows it to be classified as an old or acute dislocation. If the dislocation is repeated several times, it is called habitual.

Classification according to the direction of displacement:

Vertical in. (horizontal);

Features of the structure of the knee joint that lead to habitual dislocation (if there is no injury, then they go unnoticed and do not affect life in any way):

The presence of a shallow patellar cavity;

The presence of a poorly developed external femoral condyle;

If there is a violation of the relationship between the ligaments and the quadriceps muscle;

Initially, dislocations can occur in people running or walking. The main symptom is a sudden bending of the knee, a feeling of acute pain. With passive extension, the element can return to its original position.

Diagnosis of habitual dislocation is based on history, radiographic examination and clinical picture. The degree and direction of displacement is determined by specialists using palpation.

There are a number of common complications following a kneecap dislocation injury. The injury may be complicated by subchondral fractures or chondromalatial areas. After patellar dislocation, radiographs and MRI should be obtained before surgery. This will allow you to identify associated damage.

If the kneecap injury is primary, a series of conservative treatment procedures must be performed. When there is an imbalance of the external and internal retinaculum, special kneecaps and therapeutic exercises are used.

Certain injuries are caused by damage to the elements responsible for holding the patella. For this reason, it may shift. Such injuries are most common in a teenager or young adult who plays sports or dances.

After injury, the patella moves to the outside of the joint, which can cause a feeling of acute pain. In addition, patients notice that after some time the kneecap may return to its place. However, this case still requires immediate contact with a specialist.

In some cases, similar injuries may recur, even with little stress. This leads to “habitual dislocation” of the patella and an unstable position. The frequency of injury is one to two times per year. The emergence of instability can exacerbate the decline in quality of life. Patients may be prohibited from playing certain sports. In addition, there is a risk of arthrosis. Dislocation can develop with dysplastic changes in the knee joint.

Risk factors:

If the kneecap is high (alta);
The presence of hypotrophy of the lateral femoral condyle;
The presence of valgus deformity in the knee joint (valgum);
The presence of an increased angle Q;
Presence of internal rotation of the distal femur;
The presence of general ligamentous hypermobility;
Presence of muscle imbalance.

In addition, it is worth noting that the presented injury has anatomical features. The nature of the medial retinaculum is untenable in statistical and dynamic terms. It is necessary to distinguish between traumatic and atraumatic diseases.

Treatment of patellar luxation

The primary nature of the patellar injury suggests the use of conservative treatment. If there are unbalanced external and internal retinaculums, it is worth wearing special patellas and doing exercises.

If conservative treatment is ineffective, as well as in the presence of pronounced dysplastic changes, incompetent functioning of the retinaculum, one should proceed to surgical treatment. Operations come in many varieties.

Surgical treatment is indicated when other methods are ineffective, as well as in the presence of severe dysplasia, failure of the structures that are responsible for holding the patella. Orthopedists use various types of surgical treatment.

Preoperative preparation includes performing a clinical examination of the knee to determine the severity of the damage. Next, doctors plan precise surgical treatment of the joint.

Surgical measures will help eliminate the dislocation and correct the incorrect position of the patella. The process involves strengthening the joint capsule and plasticizing the ligaments that support the kneecap. If there is a fracture, the bone fragments can be fixed with metal screws.

The rehabilitation period lasts for seven days under the supervision of a doctor. Then the patient adheres to his recommendations. It is also worth remembering about the gentle regime, which lasts about a month. After this, you can engage in therapeutic exercises. It is worth remembering that a dislocated patella is a serious injury that requires serious treatment methods. This is what will lead to excellent results.

To correctly prescribe treatment, a correct diagnosis is required, so be sure to contact a specialist with your problem. Take care of yourself and your loved ones.

Treatment of injuries to the medial meniscus of the knee joint

Specifics of damage

The knee joint consists of the following elements:

Injuries in the knee joint are as follows:

sprained or torn ligaments;
fracture of the kneecap;
injury;
meniscus tear;
meniscal detachment.

while playing sports using the wrong technique;
twisting your ankle while running;
landing unsuccessfully after a jump;
hitting your knee on a stair step;
received a strong blow to the knee.

For reference! The menisci have the shape of a horseshoe, so they have a body and two horns, one called the upper, the second - the lower.

A rupture of the anterior horn of the medial meniscus is less dangerous, since after it only the joint is blocked. This blockage can be removed by a doctor with the necessary manual influences. But a rupture of the posterior horn, in contrast to the anterior horn, may be accompanied by a knee popping out.

Damage to the medial meniscus can be divided according to the type of tear:

Horizontal rupture is often associated with neoplasms.
Vertical, also called a “watering can handle” tear of the medial meniscus.
A transverse tear, this type of tear heals the easiest.
A flap tear most often requires surgery.
And the one that can combine several is combined.

Damage is divided into degrees:

Grade 1 is minor damage;
Grade 2 is more serious damage;
3rd degree is a gap.

It is very important not to delay visiting a doctor and treatment after damage to the medial meniscus of the knee joint.

Important! The longer the patient delays treatment, the further degenerative changes in the meniscus of the knee joint can progress.

How is the treatment carried out?

magnetic resonance;
ultrasonic;
radiographic;
tomographic.

Sometimes, for example, with instability of the medial patellar retinaculum, a firm fixation of the knee is required.

Medication assistance

During this type of treatment, medications are prescribed in both tablet and ointment form. It could be:

At the first stage, the drugs should:

Physiotherapy

Represents the effects of heat, dirt or radiation on a sore spot. They increase blood flow, thereby accelerating tissue regeneration. Types of physiotherapy:

The type of treatment is selected by the doctor individually. If it does not produce results, or the case is more serious, the therapist will refer you to a specialist:

see an orthopedic traumatologist if this is an advanced injury;
see an arthrologist if these are inflammatory diseases of the joints;
see an infectious disease specialist if the disease is bacterial.

Each of the specialist doctors may prescribe an additional examination, depending on the suspicion of a particular disease.

Important! Physiotherapy begins only after inflammation, swelling and pain are relieved. Overheating during physical therapy will only make the inflammation worse.

Operation

After examination and diagnosis, the doctor decides to treat the knee or refer it for surgery. During the operation the following actions can be performed:

Cut off the damaged part of the meniscus. It is very important that the edges of the meniscus are smooth; if this requires cutting off a part, then this is done.
Restore the meniscus. The damaged tissues are stitched together; this operation is only possible if you immediately consult a doctor after receiving an injury. Otherwise, tissue necrosis may occur, and fusion will become impossible.
Remove the meniscus. This is the most extreme case, since removal of the meniscus is accompanied by unpleasant consequences.
Replacement of the meniscus with a prosthesis or donor organ.

Nowadays the operation is mainly done using arthroscopy. Its advantages over the old method are as follows:

a small area of skin is incised;
shorter recovery time;
there is no need to fix the joint;
It is possible to monitor the progress of the operation using a high-precision camera.

Manual therapy

Since increased blood flow helps with some meniscal injuries, osteopaths can help in some way. But it is worth remembering that osteopathy is not recognized by official medicine.

Traditional methods of treatment

Traditional medicine has also prepared its own recipes for the treatment of meniscal injuries. The following is offered:

Make lotions from a mixture of honey and alcohol in equal proportions.
Make compresses from onion pulp.
Rinse your knees with a decoction of nettles and violet leaves.
Apply a burdock leaf to the sore knee.

KSS. Pathology of the patellofemoral joint (PFJ)

M.A. Gerasimenko, A.V. Beletsky, E.V. Zhuk, S.D. Zalepugin.

Pathology of the patellofemoral joint (PFJ) is a common, but insufficiently studied problem. According to some authors, approximately 15% of first-time patients have isolated patellofemoral pathology. In another 25% of patients, patellofemoral symptoms are a secondary manifestation of other diseases, such as anterior cruciate ligament instability and meniscal tears.

In most cases, patellofemoral pathology can be treated conservatively; in some cases, surgical treatment is necessary. The causes of anterior knee pain are numerous. Chondromalacia, or thinning of the joint cartilage, is one of the causes of pain in the front of the knee, but it can also be asymptomatic. Chondromalacia can be caused by a number of factors: pathological inclined position, subluxation, displacement and imbalance of muscle-tendon groups. Slip and slip problems, patellar tilt, patellar tendinosis (or quadriceps tendinosis), pathological mediapatellar fold, and fat pad trauma can also cause symptoms associated with the PFJ. Patellar instability can lead to subluxation or dislocation of the patella.

The patella has 5 articular surfaces, although 2 main surfaces are clinically important - medial and lateral. A central longitudinal ridge separates these articular surfaces. The area of contact of the patella moves proximally as the angle of knee flexion increases.

The configuration of the patella can influence its stability. Wiberg described 3 types of patella - I, II, III (Fig. 1).

In type I patella, the medial and lateral articular surfaces are equal. Types II and III have a progressively smaller medial articular surface, and a dominant lateral articular surface is likely associated with patellar instability. This suggests that the final shape of the patella is determined by the loads placed on it. For example, the outcome of a lateralized patellar plane will be a more prominent lateral articular surface. The shape of the articular end of the femur may also affect the stability of the patella. Aletti et al. noted that the height of the lateral condyle in the control group was normally almost 2 times greater than in patients with patellar subluxation, on average 9 mm versus 4.7 mm.

Medial side

Warren and Marshall depicted the anatomy of the medial aspect of the knee. A three-layer system has been described. The most important structure, the medial patellofemoral ligament (MPFL), is found in layer II, deep to the latissimus medialis. Other authors have also pointed out the importance of the copula, for example Feller et al. , who noted that it was a separate structure in autopsied corpses. The MPFL extends from the superomedial angle of the patella to the epicondyle of the femur. The MPFL is a static stabilizer of the patella. It has been shown that the MPFL is the main static stabilizer, acting as a retinaculum to the lateral displacement of the MCP joint, while the quadriceps functions as the main dynamic stabilizer. Much attention has been paid to the latissimus medialis muscle. The latissimus medialis, especially its oblique fibers (the latissimus medialis oblique, or LMO), which are oriented approximately relative to the long axis of the quadriceps tendon, play the most significant role in resisting lateral displacement. The patellar meniscal ligament and its associated retinaculum fibers were also found to play an important role, contributing (22%) to the overall resistance to displacement. Ligamentous structures can also convey proprioceptive information to surrounding musculature. The MPFL may become detached from the femur during lateral displacement of the patella. In addition, Koskinen and Kujala showed that the insertion of the latissimus medialis muscle is located more proximally in patients with dislocation than normal.

Lateral side

There is both a superficial and a deep component of the lateral retinaculum. The deep component attaches directly to the patella and is the first line of resistance to patellar displacement on the lateral side of the joint. The deep transversalis fascia anchors the iliotibial ligament of the patella. The stabilizing effect of the lateral retinaculum is most significant at the moment of full knee extension, when the articular surfaces of the patella and the femoral trochlea are not in contact. As the iliotibial ligament moves posteriorly during knee flexion, lateral tension on the patella increases. If these forces act against weakened medial stabilizers, patellar tilt or subluxation may occur.

The iliotibial tract, a continuation of the tensor fasciae lata muscle, extends from this muscle to the tubercle of Gerdy. Since the iliotibial ligament constantly rubs against the lateral epicondyle during flexion and extension of the knee, pain may occur.

Biomechanics

The primary function of the patella is to increase the efficiency of the quadriceps by increasing the leverage of the extensor mechanism. The patella increases the mechanical strength of the extensor mechanism by approximately 50%.

When the knee is flexed, the distal articular cartilage contacts the articular end of the trochlear head (trochlear groove). Initial contact is made at the distal pole of the patella with the knee flexed approximately. In the case of patella alta, this does not happen until the knee bends to. When flexion reaches 90°, the most proximal part of the patella makes contact with the articular surface of the trochlea. Depending on the location of the damage to the articular cartilage, pain may occur when bending at a certain angle. CT images have helped in understanding patellofemoral slip at different knee flexion angles. In full extension, the patella is usually located slightly lateral to the trochlea, and is lowered by the quadriceps in the center of the trochlea. The patella should be positioned centrally when the knee is flexed, without any tilt, and remain in this position throughout the entire flexion. Pathological displacement or subluxation, as well as rotation and tilt of the patella can be detected by flexion to varying degrees.

Anamnesis

Just as with any other orthopedic pathology, a thorough examination of the medical history allows a better understanding of the patient's problems. Acute traumatic injuries to the PFJ are less common than long-term problems associated with pathological displacement of the patella.

Traumatic injuries, such as a fall on a bent knee, typically cause blunt trauma to the cartilaginous surfaces of the patella and, in many cases, the femur, depending on the degree of flexion at the time of injury. In the case of an initial traumatic displacement, the patient may describe an external rotation injury of the femur on the tibia, combined with valgus and knee flexion, after which the patella is displaced laterally to the outside of the knee. While examining the patient, the patella can be moved back to its normal position. Of course, this classic history has many variations.

Nonspecific symptoms such as pain, crepitus, claudication, intermittent joint restriction and swelling are common, but they can also be a manifestation of pathology not related to the PFJ.

Pain is the most common nonspecific complaint. It is usually dull and associated with flexion-extension movements of the knee, especially climbing stairs, squatting, and sitting on a chair for long periods of time. Obesity plays a significant role as an aggravating factor in the development of patellofemoral arthrosis.

Physical examination

The physical examination may focus only on pathology related to the knee joint, while other cases, such as referred pain from the hip or lumbar spine, will be missed. Possible systemic causes such as rheumatoid arthritis and reflex sympathetic dystrophy must also be taken into account. A thorough examination can also help identify other causes of knee pain (meniscal and cruciate ligament pathology).

It is necessary to carefully examine the gait. Excessive tibiofemoral valgus deviation, hallux valgus, and pronation of the foot may be observed. There may also be excessive anterior displacement of the femur, external tibial torsion, patella alta or patella infera, and pathological medial or lateral rotation of the patella.

Proximal and lateral rotation of the patella leads to the so-called “grasshopper eye” symptom (Fig. 2). This symptom can be observed when the patient is sitting and the knees are bent at an angle of 900. This position of the patella is caused by its displacement and femoral anteversion.

It is necessary to examine the muscles around the knee joint, measure their circumference and determine the absence of atrophy - this especially applies to the quadriceps and latissimus femoris muscles. The quadriceps angle, or “Q” angle, is measured while lying down with your legs straight. The “Q” angle is determined by a line running from the superior anterior iliac spine to the patella, and from the center of the patella to the tibial tubercle (Fig. 3).

Aglietti et al. examined 150 patients with normal knee joints and found that the average Q angle was 110 in men and 170 in women. For this reason, a “Q” angle greater than 200 is considered pathological. Factors leading to an abnormal Q angle include femoral anteversion, increased external tibial torsion, and lateral displacement of the tibial tubercle. According to Fulkerson, the Q angle can be measured with the knee in 90° flexion. Examination in this position confirms that the patella is seated in the trochlear groove and an abnormal Q angle can be identified. Fulkerson set the normal values for this measurement to be -40 to +60. Results greater than 80 are considered pathological.

When examining patients in a sitting position, patellofemoral displacements can be observed by asking the patient to move the knee joint fully. One may note the sign "P" (from "patella") - excessive movement of the patella in the lateral direction with an unexpected bounce during the movement of the patella from a position of flexion to full extension. This indicates an imbalance between the medial and lateral resistance forces.

The knee joint should be examined for the presence of effusion. The peripatellar soft tissues should be carefully examined. It is necessary to carefully palpate the lateral retinaculum, as well as the insertion of the quadriceps on the patella, the patellar tendon, and the IPFL. These structures may be painful on palpation. The iliotibial ligament should be examined in flexion and extension. The ligaments bounding the popliteal fossa should also be compared in the supine position to assess possible relative shortening. In the flexion position, excessive shortening of the extensors may be detected. Normally, the patient is able to flex both knee joints so that both heels touch or almost touch the buttocks.

At the same time, crepitus can be detected, for which it is necessary to apply a small force directed posteriorly to the patella, and at the same time the examined knee joint makes active movements in full. When the patient tries to straighten the lower leg against resistance, the crepitus intensifies, and the pain also intensifies. The more proximally the injury to the articular surface of the patella is located, the greater the degree of flexion required for pain to occur.

To assess the presence of a tight lateral retinaculum, the lateral patellar margin elevation limit test should be performed (Figure 4). The test should be performed in extension, with the medial aspect of the patella held in place by the fingers of both hands while the thumbs are used to elevate the lateral aspect of the patella. If the patella can only be elevated slightly above the neutral position, then there is a tight lateral retinaculum, and possibly patellar tilt.

Kolovich et al. tested 100 patients with normal patella, and found that patellar tilt after neutral position ranged from 0 to 200. The authors concluded that failure to tilt to at least 00 was consistent with pathology, also further noting that this score correlated with with a successful outcome after lateral release surgery. Medial and lateral movements of the patella should also be carefully examined. Lateral movement of the patella reflects the integrity of the medial capsule, medial retinaculum, and oblique fibers of the latissimus medialis muscle.

X-ray studies

Standard radiographs for knee evaluation include lateral radiographs with bilateral stress anteroposterior and bilateral tangential (modified Merchant) posteroanterior views. Lateral imaging can be used to identify patella alta or patella infera. For this purpose, the Caton-Deschamps index (1982) is used, equal to the ratio of the length of the patellar tendon to the length of the patella itself. Normally, this index is equal to 1. When the index value is less than or equal to 0.6, the patella is located low (patella infera), the high location of the patella (patella alta) is diagnosed when the index value is equal to or greater than 1.2. According to other authors, the normal ratio of the length of the patella to the length of the tendon is 1+/-20%, regardless of the angle of flexion in the knee joint (Fig. 5).

The lateral view obtained in a flexion position up to 300 can also be used to identify patella alta or patella infera using the Blumensaat line. The inferior pole of the patella should be approximately level with the line that represents the roof of the intercondylar recess.

Bilateral anteroposterior imaging can be used to evaluate limb lines as well as joint space narrowing, mouse joints, fractures, tumors, and patellar pathology, including the bilobar and trilobar patella.

Anteroposterior imaging at 45° of knee flexion can diagnose tibiofemoral narrowing that otherwise goes unrecognized.

The axial view is used to diagnose patellar tilting or subluxation. Merchant described a method for obtaining this image with the knee in 450 flexion with the x-ray beam directed caudally at an angle of 300.

At the Orthopedic Institute of Southern California, a modified Merchant image is used where the knees are flexed to 300 degrees and both knees are placed on a cassette for comparison.

Then the reference lines are tangentially lowered to the lateral articular surface, the second line passes through the trochlear condyles anteriorly (analogous to the technique described by Laurin et al.). The angle formed by these lines should be open laterally. If the angle is open medially or the lines are parallel, then there is probably a pathological tilt of the patella. This conclusion was made after it was noted that 97% of people normally have divergent angles, while all patients with pathological patellar tilt have parallel or convergent angles.

Merchant's congruence angle can be used to interpret mediolateral subluxation (Figure 6). On the axial image, the line of the central ridge of the patella should be on the bisector of the sulcus angle or medial to it. If the ridge line is lateral to the bisector, then the patella is displaced laterally, which can be regarded as subluxation. In Merchant's own study of 100 patients, the normal mean congruence angle was -60, that is, the central ridge of the patella was medial to the groove angle, with a standard deviation of 110. A congruence angle of 160 was considered pathological. However, Aglietti believed that this interval is too wide. He studied 150 asymptomatic patients and found an average congruence angle of -80, with a standard deviation of 60.

CT is useful in the evaluation of more complex cases, and for patients with slight pathological obliquity. CT images are precise transpatellar transverse images obtained at various degrees of knee flexion—usually 00, 150, 300, and 450—with the posterior femoral condyles used as a reference line. The patient must be positioned upright. CT scans are used to evaluate the patellar angulation and congruence angle.

MRI can also be used to evaluate the condition of the patella, as can CT. MRI has advantages over CT due to the absence of ionizing radiation affecting the patient. Transverse images are obtained at the same knee flexion positions - 00, 150, 300, and 450. An advantage of MRI is that the surgeon can evaluate cartilage and other intra-articular pathology using a single method. Nakanishi et al. noted a positive relationship between MRI and arthroscopy findings for moderate and severe cartilage injuries. Shellock et al. also found that MRI is useful in assessing the PFJ after lateral release if the patient continues to complain of anterior knee pain. In their study, medial subluxation was observed in 74% of 43 patients with persistent symptoms after excision of the lateral retinaculum; 98% had displacement. 43% of patients had medial subluxation on the contralateral, nonoperated knee. The authors concluded that some patients likely had medial subluxation, which could be detected on preoperative MRI. The same authors compared passive positioning with active motion MRI to assess tracking. They noted that there was no difference in the qualitative assessment of patellofemoral pathology; however, active movement technologies were less time consuming and allowed the assessment of active muscle and soft tissue structures.

MRI can also be informative in cases of acute patellar dislocation. MRI in this situation can be used to determine concomitant meniscal or cruciate ligament pathology, an acute dislocation with incongruent reduction, or an acute dislocation with local weakness at the adductor tubercle. In the latter case, the patient could suffer a separation of the MPFL. In the Sallay study, 87% of patients with acute patellar dislocation had MPFL avulsion on MRI, and 94% of patients had this diagnosis confirmed at surgery. Ultimately, bone scanning may be used to confirm increased tracer uptake, indicating increased metabolic activity at the site of chronic or acute injury. Dye and Boll noted that bone scanning can identify PFJ arthrosis, and even more accurately localize it on the medial or lateral side. Bone scans can also be used to detect additional bilobed fragments in patients with bilobed patella.

Conclusion

Orthopedic pathology of the PFJ is a serious, fairly common, but not sufficiently studied problem. In diagnosing PFJ pathology, a carefully collected anamnesis and a full clinical examination are important. Considering the wide range of orthopedic diseases characterized by similar clinical and anamnestic data, in differential diagnosis and diagnosis verification it is advisable to use the entire arsenal of modern research methods (radiographs in various projections, CT, MRI), complementing traditional ones.

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Knee-joint I Knee joint (articulatio genus)

Pathology. Developmental defects. Congenital shin splints are accompanied by restriction of movements in the joint, muscle wasting, shortening of the leg, and deformation of the joint. Depending on the direction of displacement of the tibia, the joint is in a position of flexion or extension. Most often, both joints are affected. With a posterior dislocation, the condyles of the femur stand anteriorly, with anterior dislocation - posteriorly. Shortening and curvature of the lower leg (usually anteriorly) are often observed. Contracture of the cruciate ligament is noted, which, due to underdevelopment or absence of the cruciate ligaments, is combined with the drawer symptom. the lower leg can be shortened, and the flexors sometimes move anteriorly and serve as an obstacle to flexion in K. s. Lateral mobility of the lower leg is often significantly increased. clarified by x-ray examination of the joint. start from the first weeks of a child’s life. The lower leg is closed and a plaster cast is applied in the position of flexion. Therapeutic exercises and physiotherapy are prescribed. If there is no effect from conservative treatment over the age of 2 years, open reduction of the tibia or the application of a Volkov-Oganesyan hinge-distraction apparatus is indicated, with the help of which the articular ends are adjusted and movement in the joint is restored. In terms of joint function, with timely treatment, it is favorable, but with a late visit to an orthopedic doctor (after 1 year), persistent contracture often remains and develops.

Congenital contracture K. s. It is rare and can be flexor or extension. Develops as a result of relative shortening of the quadriceps femoris or tibia flexors. Typically, the restriction of movement in the joint is insignificant and is not paid attention to, but during the process of growth it progresses. Treatment should begin as early as possible. It consists of applying staged plaster casts, prescribing therapeutic exercises, massage, and paraffin-ozokerite applications. When contracture progresses, accompanied by impaired locomotor function (increased lameness), an operation is performed to lengthen the shortened muscles and connective tissue cords. The prognosis is favorable.

Congenital lateral curvatures of K. s. (lower leg - deviations to the side), unlike similar deformations of other origins, appear already at birth. There are external (genu valgum) and internal (genu varum) deviation. Often a similar structure of K. s. observed in parents as well. To clarify the diagnosis, radiography is performed. Treatment begins in the first weeks of the child’s life. It includes modeling redressing and application of a plaster cast in the position of the achieved correction. Orthopedic, plaster splints at night, therapeutic exercises and massage are prescribed. If there is no effect from conservative measures, at the age of 5-6 years, an operation is performed - corrective osteotomy of the femur or tibia. The prognosis with early treatment is favorable; if the deformity remains, osteoarthritis develops early.

Congenital dislocation of the patella is a rare developmental defect. More often, its lateral displacements (outwards) are observed. Unilateral and bilateral dislocation occurs. It is often combined with other developmental defects ( rice. 14 ) or is one of the manifestations of a systemic disease of the musculoskeletal system. Based on the degree of displacement of the patella, a distinction is made between complete dislocation and . Based on the severity of clinical manifestations, a mild degree is distinguished (there are no complaints, hypermobility of the patella is determined, it is displaced when the tibia is flexed by the lateral condyle of the femur); moderate degree (complaints of instability when walking, the patella rotates in the sagittal plane when displaced outward); severe degree (complaints of slight limitation of flexion of the leg, periodically occurring blockades of the knee, the patella is located behind and to the side in relation to the outer condyle of the femur). In children with severe congenital dislocation of the patella, outward deviation of the tibia and hypoplasia of the lateral femoral condyle are noted. Depending on the course, they are divided into recurrent and persistent. Persistent include habitual (the patella dislocates during normal movements of the knee joint) and permanent, or continuous (the patella constantly remains outside the normal path of its sliding - the so-called fixed, persistent form of dislocation). In most cases, regardless of the type of dislocation, the abnormal position of the patella or its displacement is noticed only after the child begins to walk. Treatment for mild patellar dislocation is conservative. It aims to restore the balance between the vastus externus and vastus internus muscles. Therapeutic exercises, massage, and electrical stimulation are prescribed. The use of devices that fix the patella is, as a rule, ineffective. For more severe degrees of congenital dislocation of the patella, surgery is performed. Forecast regarding the function of K. s. favorable with timely treatment.

Long-term congenital dislocation of the patella leads to the early development of osteoarthritis.

Damage. The most common is K. with., accompanied by limited hemorrhage into the periarticular fatty tissue. Patients complain of pain, which intensifies with movement. Local swelling is determined by palpation. The patellar ligament may be accompanied by hemorrhage into the subpatellar synovial bursa (bursitis), and contusion of the patella into the prepatellar bursa (prepatellar bursitis). In these cases, bulging of the corresponding bursa and its fluctuation are noted, and active extension of the lower leg is often weakened. Treatment is carried out on an outpatient basis. Shown, cold on the knee joint; apply a pressure bandage for 2-3 days, then thermal procedures and exercise therapy are prescribed. Quite often the K. is bruised. combined with hemorrhage into its cavity - hemarthrosis. It occurs when the integrity of the vessels of the synovial membrane is damaged, the joint capsule, ligaments, cartilage are damaged ( rice. 15, 16 ), menisci, subpatellar fat and bones that form K. s. It is customary to distinguish three degrees of hemarthrosis: I degree - the pain is not sharp, the contours of the joint are slightly smoothed, when the leg is flexed, bulges appear on both sides of the patellar ligament, the range of motion is not limited, the volume of blood poured into the joint cavity is no more than 15 ml; II degree - pain spread throughout the entire joint, intensifying with movements, the contours of the joint are significantly smoothed, its circumference exceeds the circumference of a healthy joint by 2-3 cm, a symptom of patellar balloting appears, the volume of blood flowing into the joint is up to 100 ml; III degree - acute pain, the contours of the joint are significantly changed, its circumference is increased by 5 cm or more, movements are sharply limited, the amount of blood in the joint is 100 ml and more. With grade II hemarthrosis, the local temperature may increase, and with grade III, so too. In addition, with pronounced hemarthrosis, a painful contracture may be observed - the lower leg is placed in a flexion position. Grade II is usually observed with damage to articular cartilage, menisci, capsule and ligaments. III degree - for intra-articular fractures, fracture dislocations and dislocations. The diagnosis of hemarthrosis of II and especially III degree in the acute period is difficult. The patient is placed in a transport splint and taken to a trauma center, where a puncture of the joint is performed to evacuate blood, and radiography of the joint is performed to identify fractures. In order to clarify the diagnosis in a specialized hospital, arthroscopy can be used. For grade I hemarthrosis, the bruised area is irrigated with chlorethyl, a pressure bandage is applied, and puncture is usually not performed. For grade II hemarthrosis, it is mandatory (sometimes repeated). After removing the blood, about 20 ml 1-2% novocaine solution. For 7-10 days, a plaster splint or splint is indicated for the joint, then physiotherapy and exercise therapy are prescribed. The knee joint is usually completely restored after 1 month. Sometimes post-traumatic recurrent (post-traumatic serous) develops, which is most often caused by undiagnosed or unrepaired intra-articular injuries. Treatment of synovitis includes joint puncture to remove effusion, immobilization of the limb for several days, and the use of desensitizing agents. Therapeutic gymnastics (without load along the axis of the lower limb), massage, and electrical stimulation of the thigh muscles are prescribed. For small amounts of effusion, compresses of medical bile with K. s., dimexide, and hydrocortisone are recommended. In case of relapse, it is administered intra-articularly (see Arthritis) .

Ruptures of the capsule and ligaments of the knee joint are common. There are complete and partial ligaments of K. s. They occur during movements that exceed physiological limits. Thus, the tibial and fibular collateral ligaments are usually torn when the tibia is excessively abducted or adducted. Anterior cruciate ligament injury can occur when a force is applied to the back surface of a semi-bent shin, especially if it is combined with rotation, and posterior cruciate ligament injury can occur when a sharp hyperextension of the shin occurs or a strong blow to its anterior surface. are damaged at the place of their attachment to the bones that form the joint, sometimes resulting in a bone fragment. along the length of the ligament there are complete, partial and intra-trunk (for example, the anterior cruciate ligament; rice. 17-19 ). The most susceptible to injury is the tibial collateral ligament ( rice. 20 ), the integrity of the anterior cruciate is less often compromised. Often both these ligaments and the internal one are damaged - the so-called unfortunate triad, or Turner's triad. Ruptures of the fibular collateral ligament can often be accompanied by damage to the peroneal nerve, and the integrity of the anterior cruciate ligament and lateral meniscus is often simultaneously compromised. Simultaneous injury to all cruciate and collateral ligaments and structures of the extensor apparatus of the leg (quadriceps tendon or patellar ligament) are the most severe type of injury to the ligamentous apparatus of the knee joint.

In the acute period, ruptures of the joint ligaments are combined with severe pain, grade II-III hemarthrosis, and reactive synovitis (see Synovial bursae) . Smoothness of the contours of the joint and a positive symptom of patellar balloting are noted. However, with extensive rupture of the joint capsule and blood flow into the periarticular tissues, this symptom may be absent. Based on the location of para-articular hemorrhages, the localization of damage to the ligamentous apparatus of the joint is judged. Thus, rupture of the tibial collateral ligament is usually accompanied by the formation of an extensive subcutaneous hematoma along the entire internal surface in the area of the joint, and damage to the posterior cruciate ligament and associated ruptures of the posterior capsule are manifested by swelling and hematoma in the popliteal region. Any damage to the ligaments of the K. s. causes severe dysfunction of the entire lower limb.

Special diagnostic techniques are of great importance when recognizing injuries to the ligamentous apparatus - the so-called stability tests, which usually involve careful passive reproduction of the mechanism of injury. for example, with a complete rupture of the tibial collateral ligament, an increase in the amplitude of passive abduction of the tibia and its outward rotation is noted, with a violation of the integrity of the anterior cruciate ligament - displacement of the tibia forward (anterior drawer symptom), with damage to the posterior cruciate ligament - displacement of the tibia backward (posterior drawer symptom) ). The degree of damage to the ligamentous-capsular apparatus of the leg is assessed by the magnitude of the deviation or displacement of the tibia. There are the following three degrees of damage to the tibial collateral ligament: I degree - complaints of pain at the site of a partial rupture, small along the inner surface of the collateral ligament, I degree; II degree - incomplete rupture with a slight divergence of the ends of the ligament, characterized by more severe pain, grade II hemarthrosis, diastasis between the ends of the torn ligament, an increase in the outward deviation of the tibia by more than 10-15° and an expansion of the internal part of the joint space on radiographs by more than 8-10 mm; III degree - complete rupture of the ligament fibers with divergence of their ends, usually combined with damage to other capsular-ligamentous structures and cartilage.

Diagnosis of damage to the capsular-ligamentous apparatus of K. s. in the acute period in the presence of hemarthrosis is difficult. In this regard, they are first removed from the joint cavity (diagnostic puncture) and about 20 ml 1% novocaine solution, which helps eliminate pain contracture and relax muscles. To clarify the diagnosis, radiography, arthrography, and ultrasound examination are performed. In some cases, arthroscopy is performed.

Treatment of acute ruptures of the capsular-ligamentous apparatus of K. s. depends on the degree of damage. So, with I-II degrees, in the first days the place is prescribed cold on the joint, for 1-3 weeks. a plaster cast is applied, then a course of exercise therapy, massage and physiotherapy is carried out. In case of severe hemarthrosis, joint puncture is necessary (sometimes repeated). Complete ligament ruptures (grade III) are an indication for surgical intervention, after which a plaster cast is applied for up to 6 weeks. To prevent significant wasting of the muscles surrounding the joint, therapeutic exercises (isometric muscle tension) and electrical stimulation of the thigh muscles are prescribed from the first days. After cessation of immobilization, exercise therapy, massage, etc. are indicated. Joint function is usually restored no earlier than after 6-8 months. after operation. The prognosis is usually favorable; sometimes a persistent contracture develops (with improper postoperative treatment). In some cases, especially after repeated injuries to the joint, post-traumatic osteoarthritis rapidly progresses until its functions are fully restored, recurrent synovitis and post-traumatic instability of the joint are noted. Depending on the nature of the displacement of the lower leg, which is caused by the functional inferiority of the capsular-ligamentous apparatus of the joint and muscles, a distinction is made between anteromedial (anterointernal), anterolateral (anterolateral), posteromedial (posterior internal), posterolateral (posterior external), anterior global and total chronic post-traumatic instability of the knee joint. The main complaint in these cases is instability in the knee joint, which impairs the support and locomotor functions of the lower limb. Treatment for mild post-traumatic instability is often conservative - therapeutic, aimed at strengthening the muscles that prevent pathological displacement of the lower leg, massage, wearing a special knee brace. Severe instability of K. s. can only be eliminated promptly. For this purpose, intra-articular autoplastic or alloplastic (for example, lavsanoplasty of joint ligaments) and extra-articular (aimed at activating the activity of the periarticular muscles) stabilizing operations are performed. After surgery, the leg is immobilized for up to 6 weeks. Early administration of therapeutic exercises, massage and physiotherapy is of great importance for restoring joint function. Supportive and locomotor functions of the lower limb are restored after 8-10 months.

Damage to the extensor apparatus of the lower leg (ruptures of the quadriceps femoris tendon and patellar ligament) is clinically manifested by a violation of the active extension of the lower leg in the absence of an obstacle to the passive performance of this movement. There are complete and partial ruptures. Palpation can usually determine the location of the rupture. A complete rupture is characterized by the absence of active extension of the leg, while a partial rupture is characterized by its more or less pronounced weakening (this is possible only in milder conditions, for example, in a position lying on its side). To clarify the diagnosis, ultrasound is used. With a complete rupture of the patellar ligament, due to muscle traction, it rises upward (proximally), which can be detected by palpation and on radiographs. Treatment of partial ruptures of the extensor apparatus of the leg is conservative - application for 3 weeks. plaster splint on K. s., exercise therapy, massage, physical exercises in water. For complete ruptures, treatment is surgical. The prognosis for joint function with timely treatment is usually favorable.

Dislocations of the lower leg are rare injuries (1-1.5% of all traumatic dislocations) and are accompanied by very serious consequences (impaired mobility of the lower limb, joint stability, damage to blood vessels and nerves). There are open and closed dislocations; According to the direction of displacement of the bones of the leg, they are divided into anterior and posterior. external, internal and rotational (posterior external dislocations are more common). In some cases, tissue is noted, making the dislocation irreducible. With any type of dislocation, the joint capsule, menisci, and ligaments are damaged. Clinically, a bayonet-shaped curvature of the lower limb and its shortening are determined. Flexion and extension of the lower leg is usually impossible, but lateral movements are preserved. In all cases, grade III hemarthrosis occurs, very often in the lower leg and foot. By palpation, the protruding condyles of the femur (for posterior dislocation) or tibia (for anterior dislocation) are determined. To clarify the diagnosis, radiography is performed. Surgical treatment of dislocations with tissue interposition. In most cases, closed dislocations are eliminated under general anesthesia using conservative methods, then a plaster cast () is applied for 8-10 weeks, which is replaced with a plaster splint for another 2-3 weeks. In the future, exercise therapy, massage, physiotherapy are prescribed, and sanatorium-resort treatment is carried out. recovers in 10-12 weeks. Often, after a dislocation, a persistent contracture or (with the early onset of movements) instability of the joint is formed. (so-called total instability). To eliminate chronic dislocations of the lower leg, the Volkov-Oganesyan hinge-distraction apparatus is used.

Traumatic patellar dislocations usually occur as a result of direct force applied to the patella in combination with a sharp contraction of the quadriceps femoris muscle. External dislocations are more common, internal dislocations are less common, and torsion dislocations are very rare, in which the patella rotates around its horizontal or vertical axis. In traumatic dislocations of the patella, its lateral supporting apparatus is torn, and in the torsion type with displacement around the horizontal axis, the quadriceps tendon and patellar ligament are torn. Clinical signs are a bulge on the outer or inner surface of the blood clot. or flattening of its anterior section, grade II-III hemarthrosis, impossibility of active movements, sharp and limitation of passive movements in the joint. Sometimes (for example, with lateral displacement of the patella) patients eliminate the dislocation on their own, which makes its objective diagnosis difficult. Usually in these cases there are factors predisposing to dislocation - valgus knee, hyperextension of the leg, hypermobility of the patella, lateral condyle of the femur, i.e. changes that are noted with congenital dislocation of the patella. Often, in the future, these patients develop a patella, the clinical manifestations of which differ little from those with congenital dislocation of mild or moderate severity. More often, this condition occurs in women during certain age periods - around 13, 17 and 24 years. In some cases, incomplete recurrent dislocations are subsequently observed - habitual subluxation of the patella. The main complaint of patients with recurrent dislocation or subluxation of the patella after injury is the instability of the knee, which manifests itself at the moment of extension of the lower leg, for example, when descending stairs, walking or running over rough terrain. To clarify the diagnosis, radiography is performed in direct, lateral and axial projections. Treatment of traumatic dislocations of the patella with lateral and torsional displacements around the vertical axis is conservative. limbs lasts up to 6 weeks, early (from the 5-7th day) administration of exercise therapy and electrical muscle stimulation is of great importance. After the joint immobilization ceases, therapeutic exercises, massage, and physiotherapy are continued. For torsional dislocation with displacement around the horizontal axis and for habitual dislocation of the patella, treatment is surgical. The function of the joint is restored within 1 year after surgery.

Damage to the menisci of the knee joint - see Articular menisci . Many injuries to the capsular-ligamentous apparatus of K. s. combined with various meniscus tears, for example Turner's triad, shin sprains.

Damage to cartilage K. s. may be isolated or combined with other intra-articular injuries. The so-called (softening of cartilage) or transchondral (for example, as a result of impression on a strictly localized area) most often occurs on the internal condyle of the femur or the internal facet of the patella. Clinical manifestations depend on the location of the damage. Thus, with chondromalacia of the patella, patients complain of pain on the anterior surface of the patella, which intensifies after a long stay in a sitting position with a bent knee, crunching when moving the patella, increased pain when tapping the patella, synovitis, and periodic blockades. To clarify the diagnosis, they carry it, which often does not give results. K. s. allows you to recognize cartilage damage and perform surgical treatment of the damaged area of the articular surface, for example, the affected area of cartilage.

Among the fractures of the bones that form K., the most common are the patella. There are transverse ( rice. 21 ), longitudinal, stellate and comminuted fractures. Clinically, these fractures resemble other injuries of the extensor apparatus of the leg. It is of decisive importance for establishing a diagnosis. Treatment of fractures without displacement is conservative, and for divergence of bone fragments - surgical (). The patella is unacceptable even with a comminuted fracture, because in this case, the extensor of the leg is significantly impaired.

Intra-articular fractures of the articular end of the femur occur as a result of both direct and indirect trauma. Fractures of the lateral condyle of the femur are more common, which is associated with physiological valgus deviation of the tibia. There are isolated fractures of the condyles without displacement and with displacement, often upward or upward and to the sides), fractures of both condyles ( rice. 22 ). which, depending on the direction of the fracture line, are T- and U-shaped. In children, epiphysiolysis and osteoepiphysiolysis are observed; in these cases, it can shift anteriorly (extension type) and posteriorly (flexion type), as well as to the sides. The most characteristic sign is grade III hemarthrosis, and when bone fragments are displaced, sometimes crepitus (see Fractures) . To clarify the diagnosis, radiography is performed.

Acquired contractures K. s. can be flexor and extension. They occur in the early stages after injury as a result of a pain reaction (reflex contracture, false), after prolonged immobilization of the joint, improper restorative treatment, etc. Within a period of up to 3 months. after injury, treatment is often conservative: for persistent arthrogenic contractures, it is indicated - iliotibial tract, lengthening of the quadriceps femoris muscle, arthrotomy with mobilization of the patella and extensor leg.

II Knee-joint

trochlear joint formed by the condyles of the femur, the articular surfaces of the tibia and the patella. The patella (kneecap) is located on the front surface of the joint. The quadriceps femoris tendon is attached to it, and the continuation of this ligament is the patellar ligament. The articular surfaces of the femur, tibia and patella are covered with cartilage. Between the articulating surfaces of the femur and tibia there are two crescent-shaped cartilages - the internal and external menisci. The entire knee joint is enclosed in a joint capsule. It has several protrusions - inversions, synovial bursae and folds containing adipose tissue. The anterior part of the joint capsule is formed by the tendon of the quadriceps muscle. K. s. strengthened by the ligamentous apparatus, which consists of the lateral and cruciate ligaments. The main movements in the knee joint are flexion and extension.

The reason for providing first aid, as a rule, is various injuries to the knee joint. With most joint injuries, blood flows into its cavity, which accumulates in the volvulus or synovial bursae. As a result of this, the shape of the joint changes - its relief is smoothed to varying degrees (the joint swells), its volume increases, pain appears, which intensifies with movements and muscle tension. In case of severe intra-articular injuries, hemorrhage (hemarthrosis) is detected soon after the injury, quickly increases, and the joint seems to swell from the inside. With milder injuries, such as a bruise, hemarthrosis may appear within a few hours or even the next day. with any hemarthrosis includes immobilization of the joint. If its volume is small, slowly increases or remains small, then for rest it is enough to apply a tight bandage, supplementing it with a small cotton-gauze circle (the so-called donut) around the patella for better compression of the inversions of the anterior part of the joint. Cold (with ice) is placed on the joint area. It is advisable to completely eliminate the load on the joint - do not step on the injured leg. should be examined by a traumatologist, because hemorrhage in the joint can be associated with damage to the menisci, ligaments, dislocation of the patella, and fractures of the articulating bones.

From ruptures of the ligaments of K. s. Injury to the medial collateral ligament is more common ( rice. 1, a ). At the same time, damage to the meniscus may occur. With a complete rupture of the ligament, pain in the joint is noted, the lower leg is easily retracted to the side. If it is partially damaged, the deviation of the tibia to the side is less pronounced. into the joint cavity is usually larger than after a bruise. There is often also bruising on the inside of the joint. anterior cruciate ligament of the knee joint ( rice. 1, b ) occurs more often in people actively involved in sports. Often this injury is combined with injury to the medial collateral ligament and meniscus. As a rule, it occurs as a result of a sharp turn and outward deviation of the tibia. Sometimes the victim hears a cracking sound, then there is pain in the joint, it begins to swell, because. blood pours into its cavity. First aid includes immobilizing the joint; you should not step on the injured leg, because strain may cause additional injury. During long-term transportation, the limbs are placed in an elevated position and cold is applied to the joint. Any suspicion of damage to the ligaments of the K. s. is an indication for transporting the victim to a specialized hospital for examination by a traumatologist and additional examination.

Damage to the meniscus K. s. immediately after the injury differ little from other injuries. In some cases, due to pinching of the torn part of the meniscus that has shifted in the joint cavity, mobility in it is limited, i.e., the so-called. In this case, you should not try to forcibly remove it, because... the meniscus or adjacent intra-articular structures may be further damaged. The injured leg is immobilized in the position in which the joint was blocked, cold is applied and the victim is taken to the hospital.

In the knee joint, luxation of the patella and dislocation of the tibia can occur ( rice. 2 ). In the first case, the patella is displaced (usually outward) in the position of the leg half-bent at the knee when the thigh is rotated inwards. As a rule, the reduction is carried out without much difficulty by the victim himself, moving the kneecap into place with his hands. In the future, it includes immobilization of the joint during transportation using a standard stair splint or improvised means. In the hospital, the spilled blood is removed from the joint cavity and a plaster cast is applied. In the absence of immobilization after reduction of a dislocated patella, habitual dislocation may subsequently develop.

A sprained leg is a very serious injury. More often it moves posteriorly (posterior dislocation) or posteriorly and outward (posterior dislocation). With a posterior dislocation, the vessels running in the popliteal region and are often damaged, and with a posterolateral dislocation, the peroneal nerve is damaged. A characteristic sign of dislocation is a change in the shape of the K. s. after injury and the inability to move in it. This dislocation needs to be repaired urgently, but this should not be attempted without general anesthesia. immobilize with a splint (preferably the Dieterichs type) or using improvised means (see Thigh). If blood circulation in the lower leg and foot is impaired, if long-term transportation is ahead, you can try to reduce the displacement, which causes compression of the blood vessels, before applying a splint. To do this, very carefully and slowly pull the foot along the longitudinal axis of the leg and lightly press the shin in the direction opposite to its displacement. You shouldn't put in much effort, because... this can cause additional injury and worsen poor circulation.

Fractures of the bones that form the blood vessels are also considered severe injuries. With a fracture of the patella, which usually occurs as a result of a fall on or a blow to the knee from the front, swelling of the joint, extensive swelling, and pain with movement and palpation are noted. As a rule, the victim cannot straighten his leg at the knee joint, but with outside help this can be done without difficulty. When the fragments of the kneecap diverge, the depression between them can be determined. First aid includes immobilizing the knee joint in full extension using a standard splint or using improvised means. Unlike most joint injuries, after immobilization the victim can walk on this leg.

Intra-articular injuries to the condyles of the femur and tibia are accompanied by severe pain in the knee area; when fragments are displaced, the shape of the joint changes; usually, hemorrhage into the joint cavity quickly increases; there is extensive hemorrhage in the joint area, which subsequently spreads to the lower leg. For immobilization during transportation, it is better to use a standard Dieterichs-type splint or improvised means. It should be remembered that an improvised one of sufficiently long length is needed - from the armpit to the foot (external) and from the perineum to the foot (internal).

In case of open damage to K. s. A sterile bandage is applied to the wound. If it is small and does not penetrate into the joint cavity, then this can be enough, but if the capsule, ligaments, dislocations or fractures are damaged, the joint should be immobilized with a splint. In case of open injuries penetrating into the joint cavity, a splint is also applied and the victim is urgently taken to the hospital for surgical treatment. If foreign objects (for example, glass) get into the joint cavity, a sterile bandage is also applied to the wound, and the joint is immobilized in the position in which it was during first aid. You should not try to remove it, even if at first glance it is located under the skin and it seems that this is possible without much difficulty, because without special treatment of the wound, this leads to additional infection of the joint cavity. When applying a bandage in this case, you need to act very carefully (do not move your leg), because possible foreign body. The bandage on the joint should not be applied too tightly.

Bandages When providing first aid, bandages are often applied to the knee joint; for small superficial wounds and abrasions, a mesh or adhesive plaster is often used. Bandages (bandages) are usually applied to this joint in a so-called turtle bandage ( rice. 3 ). The first round of the bandage is carried out through the area of the patella, then the rounds of the bandage diverge up (on the thigh) and down (on the shin), each time crossing at the back (under the knee). The so-called converging turtle bandage is used somewhat less frequently, characterized in that the first round is applied to the thigh or lower leg, and then subsequent rounds cross under the knee and gradually converge towards the middle at the level of the patella. It is better to apply turtle bandages to the knee joint if it is half-bent, and to use a figure-of-eight bandage on a straightened leg. A scarf bandage is also convenient ( Atlas of Human Anatomy- View from above. tibial tuberosity; transverse knee ligament; anterior meniscofemoral ligament; lateral meniscus; anterior cruciate ligament; posterior meniscofemoral ligament; posterior cruciate ligament; medial meniscus... Atlas of Human Anatomy

The vastus medialis muscle is the retinaculum of the patella. What is the patella, where is it located, its structure and anatomy

Specifics of damage

How is the treatment carried out?

Medication assistance

Physiotherapy

Manual therapy

Traditional methods of treatment

Posterior cruciate ligament (PCL) injuries

Injury to the medial collateral ligament

Injuries to the lateral collateral ligament

Damage to the patellar ligament

Damage to the patellar retinaculum

Literature

Causes

Classification

Symptoms

Diagnostics

Treatment

Pathogenesis

Clinical manifestations and complications

Treatment

Knee joint (normal anatomy in axial projection)

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Medial patellar retinaculum

Classification according to the direction of displacement:

Risk factors:

Treatment of patellar luxation

Treatment of injuries to the medial meniscus of the knee joint

Specifics of damage

How is the treatment carried out?

Medication assistance

Physiotherapy

Operation

Manual therapy

Traditional methods of treatment

KSS. Pathology of the patellofemoral joint (PFJ)

Medial side

Lateral side

Biomechanics

Anamnesis

Physical examination

X-ray studies

Conclusion

Literature