The vastus medialis muscle of the thigh 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 in medial parapatellar approach to the knee joint. The patient lies on his back with legs stretched out, freely 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 the 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 required, the incision can be extended distally. The subcutaneous layer is separated forward and backward, then the subpatellar branch of the saphenous nerve is isolated.

Medial parapatellar approach.
The skin incision may be arched medially to the patella or longitudinally above the patella (left knee).
An extension is possible to isolate the "crow's foot" or medial capsular-ligamentous apparatus.

in) Isolation of the knee joint. The medial patella retinaculum is incised 2 cm medial to the edge of the patella. Then, the articular capsule is bluntly withdrawn with scissors from the retinaculum and tendon of the quadriceps muscle. The knee joint traction apparatus is reinforced at the level of the proximal edge of the patella with fixation threads to ensure correct closure of the retainer. The quadriceps tendon is then dissected a few millimeters lateral to the insertion of the vastus medialis muscle of the thigh.

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

If dislocation of the patella and its rotation in the lateral direction is not possible, the incision of the quadriceps tendon and joint capsule should be extended in the proximal direction. With repeated interventions, it is sometimes necessary to perform a release in the area of the Goff's fat body (corpus adiposum infrapatellare) and the lateral joint capsule in order to be able to achieve complete dislocation and rotation of the patella.

The knee joint is then flexed at a right angle, which provides an overview of the medial and lateral condyle of the femur, the intercondylar fossa with both cruciate ligaments, the medial and lateral menisci, and the tibial plateau.

Abduction of the subpatellar branch of the saphenous nerve. Dissection of the medial patella retinaculum and quadriceps tendon. The patella and patellar tendon are dissected longitudinally for more central access to the joint in alloarthroplasty.
1. Tibial tuberosity
2. Patella
3. vastus medialis
4. Medial longitudinal patella retinaculum
5. Medial transverse patella retinaculum
6. Subpatellar branch of the saphenous nerve

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

2. Tendon of the quadriceps femoris
3. Joint capsule, synovial membrane
4. Medial superior artery and vein of the knee

Condition after opening the capsule of the knee joint and dislocation of 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. Joint capsule, fibrous sheath

Condition after bending the knee joint at a right angle. View from the ventral side. The patella is rotated outward 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. Sub-patellar fat pad
11. Subpatellar synovial fold
12. Pterygoid fold

G) Expansion of access. To highlight the "crow's foot" and the medial part of the articular capsule to the angle of the semimembranosus muscle, the incision is extended from the tuberosity of the tibia 5 cm distally. The skin incision in the proximal third corresponds to the medial parapatellar approach. After dissection of the subcutaneous layer, the subpatellar branch of the saphenous nerve is first identified and ligatures are applied. Medial arthrotomy is performed in the usual way 2 cm medial to the inner edge of the patella through the retainer.

Then the layer under the subpatellar branch rises, the nerve is lifted and the fascia and the place of attachment of the "crow's foot" are cut under it. If necessary, the incision can be extended proximal to the quadriceps tendon. The knee joint can be flexed by 90° when tilting the operating table. In this position, the fascia with tendons of the superficial crow's foot is conveniently exposed in a dorsal direction to obtain a panoramic exposure of the medial joint capsule. When detaching the superficial "crow's foot" from the tibia, it is necessary to spare the place of attachment of the medial lateral ligament located under it.

If necessary, you can also examine the back of the knee joint from the medial side. The capsule of the knee joint is opened obliquely behind the posterior internal lateral ligament and a Langenbeck hook is inserted. This incision generally provides a good view of the posterior medial 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 medially along the femur, while part of the medial head of the gastrocnemius muscle is also dissected.

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

e) Anatomy. The so-called posterior articular or semimembranous angle is of particular importance for the function of the knee joint. The posterior part of the medial joint capsule is dynamically stabilized by the semimembranosus muscle. This muscle has five attachment points, the direction of pull for them depends on the flexion of the joint: the reflex part under the medial lateral 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 the extension position. The oblique popliteal ligament is the continuation of the tendon of the semimembranosus muscle 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 popliteal muscle.

Arthrotomies in the posterior aspect of the joint can be performed either anterior or posterior to the posterior internal collateral ligament. This tibiofemoral ligament is closely related to the posterior medial 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 tendon branches of the semimembranosus muscle.

Extend the incision distally to expose the superficial crow's foot and medial capsular-ligamentous apparatus.
Dissection of the quadriceps tendon, medial patella retinaculum, and superficial crow's foot under the infrapatellar ramus.
1. Patella
2. Patellar ligament
3. Tibial tuberosity
4. Medial transverse patella retinaculum
5. vastus medialis
6. Superficial houndstooth
7. Medial head of the gastrocnemius muscle
8. Subpatellar branch of the saphenous nerve

Condition after separation of the superficial crow's foot from the tibia. The posterior sections of the joint capsule were exposed behind the superior internal lateral ligament. Caution: Save 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 Patella Retainer
5. Internal lateral ligament of the knee joint
6. Vastis medialis
7. Hamstring
8. Tendon of the large adductor muscle
9. Semimembranosus tendon
10. Superficial houndstooth
11. Medial superior artery and vein of the knee
12. Subpatellar branch of the saphenous nerve
13. Articular nerve of the knee

Extended opening of the posterior internal portions of the articular capsule by abduction of 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 Patella Retainer
6. External collateral ligament
7. vastus medialis
8. Calf muscle, medial head
9. Tendon of the large abductor muscle
10. Semimembranosus tendon
11. Superficial houndstooth
12. Medial superior artery and vein of the knee
13. Subpatellar branch of the saphenous nerve
14. Articular nerve of the knee

Anatomy. Medial capsular-ligamentous apparatus of the knee joint.
1. Vastis medialis muscle
2. Tendon of the large adductor muscle
3. Semimembranosus
4. Calf muscle, medial head
5. Medial condyle of the femur
6. Medial condyle of the tibia
7. Medial meniscus
8. Superficial houndstooth
9. Posterior medial collateral ligament
10. Medial collateral ligament
11. "Mesial ligament of the capsule"
12. "Cap" of the condyle

e) Wound closure. The articular capsule, the medial head of the gastrocnemius muscle and the separated goose 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. Exposing the knee joint through a medial parapatellar incision of the capsule can be combined with a lateral parapatellar skin incision. A lateral parapatellar skin incision is preferred for interventions such as synovectomy, arthroplasty, or ligament plasty, because it lessens 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 may be straight or arcuate, starting 5 cm proximal to the superior lateral pole of the patella to the tibial tuberosity.

For sparing dissection of the medial skin flap, the following is recommended: after dissection of the subcutaneous layer, the underlying fascia is divided along the incision. The medial skin flap is separated subfascially in the medial direction. If this order is followed, then the vessels and nerves of the medial side, which pass mainly outside the fascia, are reliably protected. Medial arthrotomy is performed in the usual way after dissection of the patella retinaculum and quadriceps tendon. From this incision, if necessary, lateral parapatellar arthrotomy, lateral release, or lateral ligament reconstructions can also be performed.

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

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

3. Patellar ligament
4. Fascia

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

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

Damage specifics

The knee joint consists of the following elements:

ligaments;
cartilage;
bones.

Injuries in the knee joint are as follows:

sprain or rupture of ligaments;
fracture of the patella;
injury;
detachment of the menisci.

Meniscal injuries are a closed type of injury, 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 such cases:

during sports in the wrong technique;
twisting your leg while running;
landing unsuccessfully after a jump;
hitting the knee on the step of the stairs;
receiving a severe blow to the knee.

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

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

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

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

Horizontal tear, often associated with neoplasms.
Vertical, it is also called a rupture of the medial meniscus according to the type of "watering can handle".
Transverse rupture, such a rupture heals the easiest.
Flap tear, most often requires surgery.
And the one that can combine several - combined.

Damage is divided into degrees:

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

It is very important not to postpone the visit to the doctor and treatment after damage to the medial meniscus of the knee joint.

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

How is the treatment carried out?

Directly with an injury, you need to go to the trauma center to the traumatologist. If a rather 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 contact a therapist. He examines the patient, prescribes tests and diagnostics. Depending on the specifics of the equipment, diagnostics is carried out using the following studies:

magnetic resonance;
ultrasonic;
radiographic;
tomographic.

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

physiotherapy;
medicines;
physiotherapy exercises;
peace;
diet.

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

Medical assistance

During this type of treatment, drugs are prescribed both in the form of tablets and in the form of ointments. It could be:

Diclofenac;
Nimesulide;
Ibuprofen.

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

At the first stage, drugs should:

remove swelling;
remove inflammation;
anesthetize.

At the recovery stage, chondroprotectors are prescribed, which can be used both in tablets and administered by injection. Increasingly, hyaluronic acid injections are beginning to be 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 give results, or the case is more serious, then the therapist will refer to a specialist:

to an orthopedic traumatologist if it is a neglected injury;
to an arthrologist if it is inflammatory diseases of the joints;
to an infectious disease specialist if these are bacterial diseases.

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

Important! Physiotherapy begins only after the removal of inflammation, swelling and pain. Overheating during physical therapy will only exacerbate inflammation.

Arthroscopy.

After examination and diagnosis, the doctor decides to treat the knee, or to send 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 even, if for this it is necessary to cut off a part, then this is done.
Repair the meniscus. Damaged tissues are sutured, this is only with immediate medical attention after injury. Otherwise, tissue necrosis may occur, and splicing will become impossible.
Remove the meniscus. This is the most extreme case, since the removal of the meniscus is accompanied by unpleasant consequences.
Replacement of the meniscus with a prosthesis or a donor organ.

Now the operation is mainly done with the help of arthroscopy. Its advantages over the old method are as follows:

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

After the operation, the doctor will observe the patient for a long time. Since the recovery period will be long, additional stimulation in the form of physiotherapy, chondroprotectors and physiotherapy exercises may be required. 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 the 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.

Folk methods of treatment

Traditional medicine has prepared for its own recipes. The following is suggested:

Make lotions from a mixture of honey and alcohol in equal proportions.
Make compresses from onion gruel.
Rinse the knees with a decoction of nettle, violet leaves.
Apply a burdock leaf to the affected knee.

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

The ACL is more likely than other ligaments of the knee joint to be torn.

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

Acute ACL rupture:

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

Indirect signs of ACL rupture:

heterogeneity or absence of the ligament in its anatomical position in the sagittal projection in the intercondylar fossa,
wavy or intermittent contour of the ligament,
displacement of the tibial and femoral parts of the ligament can detect its rupture,
increased curvature of the PCS.

Small breaks may not change the contours of the ACL, but lead to the fuzziness of its bundles. Gross ruptures 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, manifesting itself only as a complete rupture of high-signal fibers due to edema and hemorrhage at the rupture site.

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

Chronic incomplete ruptures of the ACL can cause the loss of statics. Perhaps diffuse inhomogeneous moderate signal enhancement in T1 VI. The ligament may have fuzzy edges or not be defined. Sometimes, with a significant rupture, 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 on MRI; it is not detected in the lateral part of the intercondylar fossa.

Posterior cruciate ligament (PCL) injuries

ZCL ruptures are found much less frequently than ACL.

The PCL is very strong, its complete ruptures are rare, as well as detachments at the level of attachment to the tibia or femur, along with bone fragments. In most cases, ruptures are incomplete and occur in the middle section of the ligament. In other cases, attachment to the tibia is involved, where there may be avulsion fractures.

Mechanism

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

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

Morphology

Local ligament enlargement is often noted, but ruptures do not resemble a pathological formation as much as ACL ruptures. With a complete rupture, you can find a gap separating the ligament. The ligament at rupture may have a hunchbacked or S-shaped appearance.

With subacute ruptures, foci characteristic of hemorrhages can be detected. With chronic ruptures with scars, the signal is little changed and only slight changes in the contour or displacement of the tibia can be seen. 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.

Injuries to the internal lateral ligament

Due to the normal valgus position of the knee, the internal lateral ligament is more susceptible to damage than the external one.

Injuries of the internal lateral ligament are divided into three clinical degrees:

I - rupture of a small amount of deep capsular fibers (stretching). The ligament appears normal in thickness and outline on MRI. Increased MR signal within the ligament due to T2WI edema, but fluid may also envelop the ligament.
II - rupture of up to 50% of the fibers (incomplete), the modified MR signal propagates to the surface of the ligament. Grade II lesions have features of both grades I and III and are less accurately characterized by MRI.
III - complete break. At III degree of damage, there is a complete rupture of deep capsular and superficial fibers. It is manifested by a break in the ligament, which looks like a dark strip with a thickening of its proximal and distal sections and serpentine convoluted contours. On T2VI, you can accurately localize the place of the rupture.

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

Complete ruptures of the internal lateral ligament are most often accompanied by bone contusions and trabecular microfractures of the femur and tibia. Ruptures of the ACL are also often combined with ruptures of the internal lateral ligament and bone damage.

Damage to the external lateral ligament

Damage to the lateral structures is found less frequently than the medial. Usually occur with severe trauma with varus exposure. The rupture of the external lateral ligament is manifested by the complete absence or interruption of the contours. A wavy appearance of the ligament or local accumulations of fluid is characteristic. Capsular rupture can be detected by the accumulation of fluid in the surrounding soft tissues, more often outward from the joint in the area of the hamstring muscle and tendon.

Patellar tendon injury

Patellar tendonitis usually develops in the area of the connection of the ligament with the patella. Tendinitis occurs as a result of chronic exercise and is typical of runners.

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

Patellar tendinitis is characterized by the following changes:

Thickening of more than 7 mm of the ligament at the level of the lower edge of the patella; - an increase in the intensity of the MR signal with any pulse sequences, more often localized in the anterior part of the proximal ligament; - fuzzy edges especially behind the thickened area; - increased intensity of the MR signal from the fat pad on T1WI; - the same intensity of the MR signal on T2WI and on T1WI when contrasting in combination with Hoffa's disease.

Complete rupture of the patellar ligament accompanies a tortuous course of residual distal fibers and a high location of the patella. The ligament of the patella can also have a tortuous appearance in the presence of an effusion in the anterior torsion of the joint and in case of rupture of the ACL, since the tibia, when displaced anteriorly, changes the angle of departure of the ligament of the otibial tuberosity, and the distance between the tuberosity and the patella also changes.

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

Patellar Retainer Injuries

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

Signs:

swelling of the patella retinaculum,
lengthening of the patella retinaculum,
subluxation of the patella.

Literature

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

The kneecap 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, lower leg and is held by a ligamentous apparatus formed by strong connective tissue cords.

With excessive impact on the joint in the calyx area (excessive flexion or extension of the knee, rotation of the thigh with a fixed lower leg, direct mechanical impact), a mechanical violation of the anatomical integrity of the bone, cartilage base of the patella or structures of the ligamentous apparatus 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, which aggravates the clinical symptoms of the injury.

The reasons

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

Road traffic accidents.
Household injuries.
Industrial injury.
Sports injury.

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

Fracture of the bone base, which may be with or without displacement of bone fragments. Separately, a comminuted fracture with the formation of several bone fragments is distinguished.
Dislocation of the patella, which is usually accompanied by a rupture of the ligaments.
Stretching and damage to the ligament of the patella.

A common injury is damage to the patella retinaculum (the main ligament that stabilizes the bony base of the patella). In this case, the medial supporting 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 patella retinaculum is accompanied by dislocation and damage to cartilaginous structures, the internal meniscus of the knee, the collateral ligament and tendons of the femoral muscles are injured. Injury to cartilage structures is called osteochondral damage to the patella and is usually the result of degenerative-dystrophic pathological processes in cartilage tissue (osteoarthrosis).

Symptoms

The clinical symptoms of a patella injury include several characteristic manifestations, which include:

Pain in the anterior surface of the knee in the area of localization of the patella, which usually has a high intensity and increases when trying to move.
The appearance of clicks and crunch that accompanies damage to the cartilage of the patella, in particular against the background of chondromalacia (destruction of cartilage against the background of a degenerative-dystrophic process).
Pathological mobility of the patella, which indicates that the medial patellar ligament is injured. Damage to the lateral (lateral) ligament of the knee can lead to deviation of the lower leg to the side.
Limited mobility of the knee.
Swelling of soft tissues, redness (hyperemia) of the skin, which is a sign of the development of an inflammatory reaction.

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

Diagnostics

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

radiography;
computed or magnetic resonance imaging;
arthroscopy.

The most informative but invasive procedure is arthroscopy. It is the introduction of 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 with minor injuries without disturbing the anatomical relationship of the structures of the knee. It is used if partial damage to the medial patella 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 the restoration of integrity and anatomical ratio using open access or arthroscopy.

Lateral patellar hyperpressure syndrome (LPHP) 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 relationships between the articular surfaces of the femoral condyles and the patella are disturbed, 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 various areas of the articular surfaces of the knee joint, which leads to an overload of its lateral sections.

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

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

In type I, the medial and lateral articular surfaces of the patella are equal in area, in types II and III, there is a progressive decrease in the proportion of the medial articular surface. In this case, the dominant lateral articular surface bears the bulk of the load exerted by the quadriceps, which leads to PHN. In addition, the development of SLGN is facilitated by the asymmetry of the shape of the block 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 in the norm.

In addition to bone-cartilaginous 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, is the main static stabilizer of the patella, which acts as a retainer for 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 PHN and lateroposition of the patella, the area of attachment of the medial head of the quadriceps is located more proximally than in the norm, which does not allow the muscle to realize a dynamic-stabilizing function.

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

Pathogenesis

The pathogenesis of the progression of SLGN can be represented as follows: as a result of overloading the lateral parts of the PFS, the level of stress in the bone-cartilaginous and soft tissue elements of the joint increases, which leads to the development of chondromalacia, asymmetric wear of the joint with the development of degenerative changes in bone-cartilaginous 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 (aggravated by 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, crunching during movement. With the progression of hyperpressure, a feeling of instability, looseness in the joint, pain pseudo-blocking of the joint may appear.

Complications of SLGN can be chondral and osteochondral fractures of the lateral condyle of the femur, medial and lateral facets of the patella, with a long course with traumatic episodes, habitual dislocations of the patella can be observed. To prevent complications in patients with PHN, it is necessary to pay special attention to a thorough examination of patients in order to detect signs of this pathology in them early. In the diagnosis of PHN, a thorough history of the disease, assessment of the 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 method of treatment, it is important to conduct a test to limit the elevation of the lateral edge of the patella: for example, the impossibility of raising to a neutral position at 0° indicates a tight lateral patella retinaculum. An important role in the diagnosis of SLGN is also played by the measurement of the Q angle, or the angle of the quadriceps 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° should be regarded as pathological.

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

Treatment

Treatment of SLGN can be conservative and operative. Conservative therapy consists in carrying out active exercises, massage, wearing fixators on the knee joint. Activities 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, requires significant effort on the part of the patient, but can be effective in 75% of cases.

Among the open techniques, which, according to Marion and Barcat, there were about 100 already in 1950, the most common modifications of operations according to Roux (Fig. 3, A: moving the tuberositas tibiae inwards), according to Krogius (Fig. 3, B: c on the outer side of the joint parallel to the patella, a capsule incision about 15 cm long is made; on the inside, 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 from above covering the part of the fibers of m. vastus tibialis; patella they are pulled inward, while the external gap is opened, 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 together with the patellar ligament, their movement in the medial direction with fixation to the tendons of the tailor, large adductor and medial wide muscles of the thigh and suturing the joint capsule from the medial side into the longitudinal fold). However, these techniques require a wide skin incision, long-term postoperative immobilization, and long-term rehabilitation of the limb.

Possible complications such as secondary osteoarthritis, progression of retropatellar arthrosis with the development of medial hyperpressure, fatigue fractures of the tibia as a result of the transplant, neuritis, bursitis, secondary chondromalacia, etc.

In 1972, Chen and Ramanathan proposed the following technique for the treatment of SLGN: after preliminary diagnostic arthroscopy, through the available arthroscopic accesses (inferior and, if necessary, upper lateral), the lateral portion of the extensor apparatus is released (i.e., dissected) from inside the knee joint (using an electrocoagulation knife or a Smillie knife). This technique is characterized by significant efficiency and safety: the complication rate is less than 10%. In 1995, Henry and Pflum supplemented this technique with arthroscopic suturing of the medial retainer using a special instrument and thus creating its fold (riffling).

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 the case when an 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 the tactics of further treatment.

Separately, it is necessary to note the cases of traumatic injuries of the patellofemoral joint area against the background of SLGN. In most cases, they lead to an osteochondral fracture of the lateral or medial facet of the patella or lateral femoral condyle, and a 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 the removal of a free fragment of the patella from the joint cavity with the restoration of joint function. To restore normal biomechanical relationships in the knee joint, eliminate the lateral hyperpressure syndrome and remove the affected part of the patella from increased load, in some cases we supplement this intervention with a 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 the healing of the wound surface.

So, when performing diagnostic arthroscopy and detecting a large osteochondral fragment of the patella facet, the dimensions of which do not allow it to be removed from the joint cavity through arthroscopic punctures, an upper lateral microarthrotomy up to 2 cm in size is performed. The osteochondral fragment is removed through this hole. The surgeon examines the facet of the patella and lateral femoral condyle to assess the condition of the wound surface and, if necessary, performs their arthroscopic abrasive chondroplasty. Then, having lifted the skin from the wound proximal to the microarthrotomy approach, the surgeon with a scalpel, under the control of a finger inserted into the joint cavity, dissects the lateral retinaculum of the patella for 1-2 cm, drawing the incision line as close as possible to the edge of the patella and, at the same time, being afraid of incision of 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 hyperpressure syndrome allows 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 the normal biomechanical functioning of the knee joint and accelerated healing of the defect in the articular surface of the patella .

According to Crosby and Insall, 7% of patients who underwent open surgery for the correction of PHN 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 PHN (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 PHN using the traditional technique: a patient with a 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 - satisfactory.

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

The average age of operated patients was 13.5 (from 5 to 25) years. There were 13 girls (56.5%) among the patients, 10 (43.5%) boys. The average length of stay of patients in the 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 intervention were allowed to exert a 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 followed up in 12 patients (9 of them underwent open surgery, 3 - arthroscopic).

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

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Attention! The information on the site is not a medical diagnosis, or a guide to action, and is intended for informational purposes only.

Knee joint (normal anatomy in axial view)

1. Quadriceps tendon 2. Vast medialis femoris 3. Femur 4. Vasso lateralis femoris 5. Tailor muscle 6. Tibial nerve 7. Biceps femoris 8. Glenosa muscle 9. Semimembranosus muscle 10. Semitendinosus muscle 11. Lateral head 12. Medial head of gastrocnemius 13. Common peroneal nerve 14. Medial patellar retinaculum 15. Lateral patellar retinaculum 16. Patella 17. Medial collateral ligament 18. Patellar cartilage 19. Peroneal collateral ligament 20. Anterior cruciate ligament 21. Popliteal tendon 22. Posterior cruciate ligament 23. Iliotibial tract 24. Lateral meniscus 25. Patellar tendon 26. Medial meniscus 27. Anterior ligament of the head of the fibula 28. Popliteal muscle 29. Tuberosity of the tibia 30. Anterior tibialis muscle

Dislocation of the patella

Smetanin Sergey Mikhailovich

traumatologist - orthopedist, candidate of medical sciences

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

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

From 2007 to 2009, he studied in clinical internship 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. Solovyov.

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 adviser, professor V.V. Klyuchevsky.

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

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

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

February 18, 2014 - Orthopedic surgery workshop "Knee and hip arthroplasty", Dr. Patrick Mouret, Klinikum Frankfurt Hoechst, Germany.

November 28-29, 2014 - training course on knee arthroplasty. Professor Kornilov N.N. (RNIITO named after R.R. Vreden, St. Petersburg), Kuropatkin G.V., Sedova O.N. (Samara), Kaminsky A.V. (Kurgan). Theme "Course on the balance of ligaments in primary knee arthroplasty", Morphological Center, Yekaterinburg.

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

Scientific and practical interests: arthroplasty 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 lower pole of the patella is the ligament of the patella, which goes to the tuberosity of the tibia. The quadriceps femoris muscle is attached to the upper pole of the patella. The patella is involved in the extension of the lower leg. Patella retainers are attached to the inner and outer surfaces of the patella to help center the patella during movement. When extended, the patella is freely located in the cavity of the knee joint, and when flexed, it fits snugly against a special groove on the femur - a femoral patella joint is formed. The surface of the patella that slides over the femur is articular, covered with thick cartilage.

Two surfaces of the patella - articular surface on the right

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

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

There is hyperpressure 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 hyperpressure, the patella presses on the outer facet, with an even greater displacement, subluxation of the patella appears, with complete displacement, dislocation.

On the left - subluxation of the patella, a tendency to move outwards; right - dislocation of the patella

Causes of dislocation of the patella

Weakness of the internal retaining ligaments, weakness of the thigh muscle, dysplasia of the condyles of the femur, high standing of the patella, weakness or overexertion of the patella 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 external condyle, while the patella is more easily displaced outward; dysplasia of the internal condyle, in which it is easier for the patella to move inward.

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

Symptoms of dislocation of the patella

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

Schematic displacement of the patella outward

One of the causes of a dislocated patella is damage to the internal patella retinaculum.

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

Examination of a leg with suspected patella instability

Dislocation of the patella outward

Diagnosis of dislocation of the patella

To clarify the diagnosis, x-rays, magnetic resonance imaging or computed tomography are performed. X-ray images are performed in frontal, 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 distance between the tuberosity of the tibia 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 dislocations of the patella

Treatment of dislocation of the patella is conservative and operative. The basis of conservative treatment includes physical exercises, taping and the use of special orthoses.

Operation for dislocation of the patella

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

If the patella retainer is damaged, an operation is performed to strengthen it. One option for retinaplasty is the Medial Patellofemoral Ligament (MPFL) operation. The essence of the operation is to replace the torn patella retinaculum with a graft from the patient's tendon and fix it to the patella and femur at the point when the grafts are evenly tensioned during flexion in the knee joint.

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

Reconstruction Scheme (MPFL)

Orthosis on the knee joint

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

Treatment of dislocation of the patella of the knee joint in Germany

Our expert:

Dr. Peter Angele

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

Sports orthopedist, surgeon FIFA official. Head of the FIFA Clinic. Specialist in cartilage transplantation of the knee joint. Instructor of the European Association of Arthroscopy and Joint Surgery (AGA). Conducts minimally invasive interventions per year.

A fairly common problem in the area of the anterior knee joint is acute dislocation of the patella. We mean lateral or external acute patellar dislocation because medial or internal patellar dislocation is vanishingly rare. The increasing frequency of primary dislocations of the patella is associated primarily with an increase in commitment to active sports associated with a sharp change in direction of movement.

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

Patella Injury: Symptoms and Causes

Anatomically, the patella tends to move outward with movements of the knee joint. The higher the force directed to flexion or extension of the knee joint, the more the patella moves outward. This displacement is opposed by two anatomical structures: the femoral block and the medial (internal) patella retinaculum. If the force that displaces the patella outward exceeds the elasticity of the medial (internal) retainer, this retainer ruptures with dislocation of the patella, which is accompanied by acute pain, a feeling that “something has shifted and fallen 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.

For the correct diagnosis of primary dislocation of the patella of the knee joint in Germany, a competent orthopedic traumatologist, after a clinical examination and a thorough questioning of the patient about the mechanism of injury, will perform radiographs of the knee joint and recommend an MRI examination of the knee joint. In the case when the patella, dislocated, does not fall into 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 make a correct diagnosis of this damage to the knee joint, since acute dislocation of the patella in terms of the clinic and the mechanism of injury is very similar to the rupture of the anterior cruciate ligament.

Treatment of injuries of 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 other than the medial patella retinaculum, a positive result is obtained by conservative treatment, which consists in immobilizing the knee joint in a comfortable straight orthosis within 3 weeks from the moment of injury. If there is a large accumulation of blood in the cavity of the knee joint (unavoidable, unfortunately, in case of acute injuries), a competent orthopedic traumatologist will perform a puncture of the knee joint with strict observance of asepsis and antisepsis. Particular attention should be paid to the problems of thrombosis prevention: a competent orthopedic traumatologist will recommend compression stockings and special preparations 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 physiotherapy, careful development of knee joint movements 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 an active lifestyle is high even without surgical treatment.

In the case when, in addition to the medial patella retinaculum, during acute patellar dislocation, 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 an incorrectly chosen treatment strategy can lead to the formation of chronic instability of the patella, which manifests itself in its constant dislocations and destruction of the articular cartilage.

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

Surgical treatment for fracture of the patella

Depending on the type of damage or rupture of the medial femoral-patellar ligament, an orthopedic trauma surgeon will recommend one or another type of surgical treatment. Surgical treatment may consist of either attempting to suture the damaged medial patellar retinaculum or plasty of the femoropatellar ligament with an autograft from one of the patient's own tendons. This ensures the best graft survival, the absence of allergic reactions when 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 full from the earliest postoperative 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 tactic 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 the previous sports loads and reach new heights as soon as possible after the injury. And conservative. and surgical treatment have the right to exist, the choice should be made after a thorough analysis of each case of acute patellar luxation in Germany with a comprehensive complete examination.

Medial Patella Retainer

The patella, also called the patella, are small rounded flat bones. They are located on the front of the knee joints. Tendons are attached to them, extending to the quadriceps femoral muscles. 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 patellofemoral. It is it that performs the operation of sliding the patella when moving a person.

The patella is located in a recess where it can be held with the help of ligaments and tendons coming from the quadriceps muscle. The restriction of mobility is carried out by the femoral condyle. The kneecaps protect the joints from various external influences.

Trauma can be acquired or congenital. The prescription of the injury allows us to classify it in the category of chronic or acute dislocations. If the dislocation is repeated several times, it is called habitual.

Classification according to the direction of displacements:

Vertical in. (horizontal);

Features of the device of the knee joint, which 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 small patella;

The presence of a poorly developed external condyle of the thigh;

In case of violation of the ratio of the ligaments and the quadriceps muscle;

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

Habitual dislocation is diagnosed based on the history, radiographic examination and clinical picture. The indicator of the degree and direction of displacements is determined by specialists by palpation.

There are a number of common complications after an injury associated with a dislocated patella. The injury may be complicated by subchondral fractures or chondromalative areas. After a dislocation of the patella, X-ray and MRI data should be obtained before surgery. This will help identify associated damage.

If the injury to the patella is primary, a number of conservative treatment procedures should be performed. With an imbalance of the external and internal retainers, special patellas and therapeutic exercises are used.

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

After injury, the patella is displaced to the outside of the joint, which can cause a sensation of acute pain. In addition, patients notice that after some time the patella may return to its place. However, this case still requires immediate medical attention.

In some cases, repetition of similar injuries is possible, as well as with a slight load. This leads to a "habitual dislocation" of the patella and an unstable position. The degree of frequency of injury is one to two times a year. The appearance of instability can exacerbate the decline in the quality of life. Patients may be banned from certain sports. In addition, there is a risk of arthrosis. A dislocation can develop with dysplastic changes in the knee joint.

Risk factors:

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

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

Patella Dislocation Treatment

The primary nature of the patella injury suggests the use of conservative treatment. If there are imbalanced external and internal restraints, it is worth wearing special patellas and exercising.

If conservative treatment is ineffective, as well as in the presence of a pronounced dysplastic change, incompetent functioning of the retainer, one should proceed to surgical treatment. Operations are of many types.

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 a variety of types of surgical treatment.

Preoperative preparations include performing a clinical evaluation of the knee to determine the severity of the injury. Next, doctors plan precise surgical treatment of the joint.

Operative measures will help eliminate dislocation, correct the incorrect position of the patella. The process involves strengthening the joint capsule and plasty of the ligaments that hold the kneecap. If there is a fracture, fragmental elements of the bone can be fixed with metal screws.

The rehabilitation period lasts for seven days under the supervision of a doctor. Further, the patient adheres to his recommendations. It is also worth remembering the sparing regimen, which lasts about a month. After that, you can do therapeutic exercises. It is worth remembering that dislocation of the patella is a serious injury that requires serious methods of treatment. This is what will lead to excellent results.

To prescribe the right 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 damage to the medial meniscus of the knee joint

Damage specifics

The knee joint consists of the following elements:

Injuries in the knee joint are as follows:

sprain or rupture of ligaments;
fracture of the patella;
injury;
meniscus rupture;
detachment of the menisci.

during sports in the wrong technique;
twisting your leg while running;
landing unsuccessfully after a jump;
hitting the knee on the step of the stairs;
receiving a severe blow to the knee.

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

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

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

Horizontal tear, often associated with neoplasms.
Vertical, it is also called a rupture of the medial meniscus according to the type of "watering can handle".
Transverse rupture, such a rupture heals the easiest.
Flap tear, most often requires surgery.
And the one that can combine several - combined.

Damage is divided into degrees:

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

It is very important not to postpone the visit to the doctor and treatment after damage to the medial meniscus of the knee joint.

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

How is the treatment carried out?

magnetic resonance;
ultrasonic;
radiographic;
tomographic.

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

Medical assistance

During this type of treatment, drugs are prescribed both in the form of tablets and in the form of ointments. It could be:

At the first stage, 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 give results, or the case is more serious, then the therapist will refer to a specialist:

to an orthopedic traumatologist if it is a neglected injury;
to an arthrologist if it is inflammatory diseases of the joints;
to an infectious disease specialist if these are bacterial diseases.

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

Important! Physiotherapy begins only after the removal of inflammation, swelling and pain. Overheating during physical therapy will only exacerbate inflammation.

Operation

After examination and diagnosis, the doctor decides to treat the knee, or to send 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 even, if for this it is necessary to cut off a part, then this is done.
Repair the meniscus. Damaged tissues are sutured, this operation is possible only with immediate medical attention after injury. Otherwise, tissue necrosis may occur, and splicing will become impossible.
Remove the meniscus. This is the most extreme case, since the removal of the meniscus is accompanied by unpleasant consequences.
Replacement of the meniscus with a prosthesis or a donor organ.

Now the operation is mainly done with the help of arthroscopy. Its advantages over the old method are as follows:

a small area of the skin is incised;
shorter recovery time;
no need to fix the joint;
It is possible to observe the progress of the operation with the help of 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.

Folk methods of treatment

Traditional medicine has prepared its own recipes for the treatment of meniscus injuries. The following is suggested:

Make lotions from a mixture of honey and alcohol in equal proportions.
Make compresses from onion gruel.
Rinse the knees with a decoction of nettle, violet leaves.
Apply a burdock leaf to the affected 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 cured conservatively, in some cases surgical treatment is necessary. The causes of pain in the anterior part of the knee joint are numerous. Chondromalacia, or thinning of the articular cartilage, is one of the causes of pain in the front of the knee, but it can be asymptomatic. Chondromalacia can be caused by a number of factors: pathological oblique position, subluxation, displacement and imbalance of the muscle-tendon groups. Shift and slip problems, patella tilt, patellar tendinosis (or quadriceps tendinosis), abnormal mediapatellar fold, trauma to the fat pad can all also cause symptoms associated with PFS. 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. The 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 affect 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 decreasing 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 stresses placed on it. For example, the outcome of the lateralized plane of the patella will be a more protruding lateral articular surface. The shape of the block of the articular end of the femur can also affect the stability of the patella. Agletti 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 side of the knee. A three-layer system has been described. The most important structure, the medial patellofemoral ligament (MPFL), is located in layer II, deeper than the medial latissimus femoris. Other authors have also pointed out the importance of the bond, such as Feller et al. , who noted that it was a separate structure in the opened corpses. The MPFS spans from the superior medial angle of the patella to the epicondyle of the femur. The MPFS is a static patella stabilizer. It is shown that the MPPS is the main static stabilizer, which plays the role of a retainer to the lateral displacement of the PPS, while the quadriceps functions as the main dynamic stabilizer. Much attention has been paid to the medial latissimus femoris. The medial latissimus femoris, especially its oblique fibers (the oblique medial latissimus femoris, or LMTF), which are oriented roughly in relation to the long axis of the quadriceps tendon, play the most significant role in resisting lateral displacement. The patellar-meniscal ligament and its associated retaining fibers were also found to play an important role, contributing (22%) to the overall displacement resistance. Ligament structures can also transmit proprioceptive information to the surrounding musculature. The MPFS may come off the femur during lateral displacement of the patella. In addition, Koskinen and Kujala showed that the insertion of the medial latissimus femoris muscle is located more proximally in patients who have undergone a dislocation than in the norm.

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 displacement of the patella from the lateral side of the joint. The deep transverse fascia fixes the ilio-tibial ligament of the patella. The stabilizing effect of the lateral retainer is most significant at the moment of full knee extension, when the articular surfaces of the patella and the femoral block do not touch. As the iliotibial ligament moves posteriorly during knee flexion, lateral tension on the patella increases. If these forces act against the weakened medial stabilizers, patellar tilt or subluxation can occur.

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

Biomechanics

The main 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 force of the extensor mechanism by about 50%.

When the knee is flexed, the distal articular cartilage contacts the articular end of the head of the block (trochlear groove). Initial contact is made at the distal pole of the patella with knee flexion of approximately. In the case of patella alta, this does not happen until the knee is bent to. When flexion reaches 900, the most proximal part of the patella contacts the articular surface with the block. Depending on the location of the damage to the articular cartilage, pain may occur when bending at a certain angle. The CT images helped in understanding the patellofemoral glide at various knee flexion angles. In the full extension position, the patella is usually slightly lateral to the block, and lowered by the quadriceps in the center of the block. The patella should be centered when the knee is bent forward, without any tilt, and remain in that position throughout the entire flexion. Pathological displacement or subluxation, as well as rotation and tilt of the patella, can be detected with flexion to a different number of degrees.

Anamnesis

Just as with any other orthopedic pathology, a careful study of the anamnesis allows you to better understand the problems of patients. Acute traumatic injuries of 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, usually cause blunt injury to the cartilaginous surfaces of the patella and in many cases to the femur, depending on the degree of flexion at the time of injury. In the case of initial traumatic displacement, the patient may describe an external rotational femur injury on the tibia, combined with valgus and knee flexion, after which the patella is displaced laterally, to the outside of the knee. During examination of the patient, the patella can be moved back to its normal position. Of course, this classic anamnesis has many variations.

Non-specific symptoms such as pain, crepitus, lameness, intermittent joint stiffness, and swelling are common, but they can also be a manifestation of pathology not associated with PFS.

Pain is the most common non-specific complaint. It is usually blunt, associated with flexion-extension movements at the knee joint, especially climbing stairs, squatting, and sitting in 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 joint or lumbar spine, will be missed. It is also necessary to take into account possible systemic causes, such as rheumatoid arthritis and reflex sympathetic dystrophy. A thorough examination also helps to identify other causes of knee pain (meniscal and cruciate ligament pathology).

The gait must be carefully examined. Excessive tibiofemoral valgus, valgus, and pronation of the foot may be seen. There may also be excessive anterior displacement of the femur, external tibial torsion, patella alta or patella infera, and abnormal medial or lateral rotation of the patella.

Proximal and lateral rotation of the patella leads to the appearance of the so-called "grasshopper's eye" symptom (Fig. 2). This symptom can be observed when the patient is seated with the knees bent at 90°. 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 is especially true for the quadriceps and the latissimus femoris. The quadriceps angle, or "Q" angle, is measured while lying down with legs extended. The angle "Q" is determined by the 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 value of the angle "Q" is 110 in men and 170 in women. For this reason, the "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 at 90° flexion at the knee joint. Examination in this position confirms that the patella is seated in the groove of the block, and an abnormal "Q" angle can be detected. Fulkerson set the normal readings for this measurement to be -40 to +60. Results over 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 in full. The sign "P" (from "patella") can be noted - excessive movement of the patella in the lateral direction with an unexpected jump during the movement of the patella from the position of flexion to full extension. This is indicative of an imbalance between medial and lateral resistance forces.

The knee joint should be examined for effusion. The peripatellar soft tissues should be carefully examined. The lateral retinaculum should be carefully palpated, as well as the attachment of the quadriceps to the patella, the patellar tendon, and MPPS. These structures may be painful on palpation. In the position of flexion and extension, it is necessary to examine the iliotibial ligament. The ligaments limiting the popliteal fossa should also be compared in the supine position to assess possible relative shortening. Excessive shortening of the extensors may be seen in the flexion position. Normally, the patient is able to flex both knees so that both heels are in contact or almost in contact with the buttocks.

At the same time, crepitus can be detected, for which it is necessary to apply a small force directed backwards 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, crepitus increases, and pain also increases. The more proximal the damage to the articular surface of the patella, the greater the degree of flexion required for the onset of pain.

To assess the presence of a tight lateral retinaculum, a lateral patellar elevation limitation test should be performed (Fig. 4). The test should be carried out in extension, with the medial patella held in place with the fingers of both hands while the thumbs are used to lift the lateral patella. If the patella can only be raised slightly above the neutral position, then there is a tight lateral retinaculum, and possibly a tilt of the patella.

Kolowich et al. tested 100 patients with a normal patella and found that the patella tilt after passing through the neutral position ranged from 0 to 200. The authors concluded that the inability to tilt to at least 00 was pathological, also noting further that this index with a successful outcome after lateral release surgery. The medial and lateral movements of the patella should also be carefully examined. Lateral movements of the patella reflect the integrity of the medial capsule, medial retinaculum, and oblique fibers of the medial latissimus femoris.

X-ray studies

Standard radiographs for assessing the knee joint include lateral radiographs with bilateral anteroposterior loading and bilateral tangential (modified by Merchant) posterior anterior images. The side view can be used to identify patella alta or patella infera. For this, the Caton-Deschamps index (1982) is used, which is equal to the ratio of the length of the tendon of the patella to the length of the patella itself. Normally, this index is equal to 1. If the index value is less than or equal to 0.6, the patella is located low (patella infera), the high position 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 flexion up to 300 can also be used to identify patella alta or patella infera using the Blumensaat line. The lower pole of the patella should be approximately level with the line that represents the roof of the intercondylar recess.

Bilateral AP imaging can be used to assess limb lines as well as joint space narrowing, joint mice, fractures, tumors, and patellar pathology, including bilobed and trilobe patella.

Anteroposterior imaging at 450 knee flexion can diagnose tibiofemoral constriction that would otherwise go unrecognized.

Axial projection is used to diagnose patellar tilt or subluxation. Merchant described a method for obtaining this image while bending the knee at 45° with a 30° caudal x-ray beam.

The Orthopedic Institute of Southern California uses a modified Merchant image where the knees are flexed to 300 and both knees are placed on a cassette for comparison.

The reference lines are then tangentially lowered onto the lateral articular surface, the second line passing through the condyles of the trochlea anteriorly (similar 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 an abnormal patella tilt. This conclusion was made after it was noted that 97% of people normally have divergent angulations, while all patients with abnormal patella inclination have parallel or convergent angulations.

The Merchant congruence angle can be used to interpret mediolateral subluxation (Figure 6). On the axial image, the line of the central crest of the patella should be on the bisector of the sulcus angle or medially from it. If the crest line is located laterally from 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, meaning the central patella crest was medial to the sulcus angle, with a standard deviation of 110. A congruence angle of 160 was considered abnormal. However, Aglietti believed that this interval is too wide. He studied 150 asymptomatic patients and found that the mean angle of congruence was -80, with a standard deviation of 60.

CT is useful in evaluating more complex cases, and for patients with mild pathologic angulation. CT images are accurate transpatellar transverse images taken at various degrees of knee flexion—usually 00, 150, 300, and 450—and the posterior femoral condyles are used as a guideline. The patient must be placed upright. CT images are used to evaluate the angle of the patella and the angle of congruence.

MRI can also be used to assess the condition of the patella, as well as CT. MRI has advantages over CT due to the absence of ionizing radiation affecting the patient. Transverse images are taken at the same knee flexion positions - 00, 150, 300, and 450. MRI also has the advantage that the surgeon can evaluate cartilage and other intra-articular pathology using a single method. Nakanish et al. noted a positive relationship between MRI and arthroscopy findings for moderate to severe cartilage lesions. Shellock et al. also found that MRI is useful in evaluating PFJ after lateral release if the patient continues to complain of anterior knee pain. In their study, medial subluxation occurred in 74% of 43 patients, with persisting symptoms after excision of the lateral retinaculum; 98% had displacement. 43% of patients had medial subluxation on the opposite, non-operated knee. The authors concluded that some patients probably had medial subluxation, which could be identified on preoperative MRI. The same authors compared passive positioning with active MRI movements 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 may also be informative in the case of acute dislocation of the patella. MRI in this situation can be used to identify associated meniscal or cruciate ligament pathology, acute dislocation with incongruent reduction, or acute dislocation with local weakness at the adductor tubercle. In the latter case, the patient could tolerate MPPS detachment. In the Sallay study, 87% of patients with acute patellar dislocation had MPPS avulsion on MRI, and 94% of patients had this diagnosis confirmed at surgery. Ultimately, a bone scan may be used to confirm an increase in tracer uptake, indicative of increased metabolic activity at the site of chronic or acute injury. Dye and Boll noted that when scanning the bone, arthrosis of the PFJ can be determined, and even more accurately localized from the medial or lateral side. Bone scanning may also be used to detect additional bilobed fragments in patients with a bilobed patella.

Conclusion

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

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Knee-joint I Knee joint (articulatio genus)

Pathology. Developmental defects. The congenital tibia is accompanied by limitation of movements in K. s., muscle hypotrophy, shortening of the leg, and joint deformity. Depending on the direction of displacement of the lower leg, the joint is in the position of flexion or extension. Both joints are most commonly affected. With a posterior dislocation, the condyles of the femur will stand anteriorly, with an anterior dislocation - posteriorly. Shortening and curvature of the lower leg (usually anteriorly) are often observed. Contracture is noted K. with., which, due to underdevelopment or lack of cruciate ligaments, is combined with a symptom of a drawer. the lower leg can be shortened, and the flexors sometimes move anteriorly and serve as an obstacle to flexion in K. s. The 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. A closed leg is carried out and plaster casts are applied in the flexion position To. Assign therapeutic exercises, physiotherapy. In the absence of the effect of conservative treatment over the age of 2 years, an open reduction of the lower leg or the application of the Volkov-Oganesyan hinge-distraction apparatus is indicated, with the help of which the articular ends are arranged and movements in the joint are restored. in relation to the function of the joint, with timely treatment, it is favorable, with a late visit to an orthopedist (after 1 year), persistent contracture often remains and develops.

Congenital contracture To. is rare, can be flexion and extensor. It develops as a result of a relative shortening of the quadriceps femoris or calf flexors. Usually, the limitation of movements in the joint is expressed slightly and is not paid attention to, but in the process of growth it progresses. Treatment should begin as soon as possible. It consists in the imposition of stage plaster bandages, the appointment of therapeutic exercises, massage, paraffin-ozokerite applications. With the progression of contracture, accompanied by a violation of the locomotor function (increased lameness), an operation is performed - lengthening of the shortened muscles and connective tissue strands. The prognosis is favorable.

Congenital lateral curvature To. (shins - its deviations to the side), in contrast to similar deformities of a different origin, appear already at birth. There are external (genu valgum) and internal (genu varum) deviation. Often similar structure To. observed in parents. To clarify the diagnosis, an x-ray is performed. Treatment begins in the first weeks of a child's life. It includes modeling redressing and the application of a plaster cast in the position of the achieved correction. Assign orthopedic, gypsum splints for the night, therapeutic exercises and massage. In the absence of the effect of conservative measures at the age of 5-6 years, an operation is performed - corrective osteotomy of the femur or tibia. The prognosis for early treatment is favorable, with preserved deformity, osteoarthritis develops early.

Congenital dislocation of the patella is a rare malformation. Its lateral displacements (outwards) are more often observed. There is unilateral and bilateral dislocation. Often it is combined with other malformations ( rice. fourteen ) or is one of the manifestations of a systemic disease of the musculoskeletal system. According to the degree of displacement of the patella, complete dislocation and are distinguished. According to the severity of clinical manifestations, a mild degree is distinguished (no complaints, hypermobility of the patella is determined, it is displaced when the leg is bent by the external condyle of the femur); medium degree (complaints of instability when walking, the patella rotates in the sagittal plane when displaced outwards); severe degree (complaints of a slight restriction of flexion of the lower leg, intermittent blockades of K. s., the patella is located behind and to the side in relation to the external condyle of the femur). In children with severe congenital dislocation of the patella, an outward deviation of the lower leg and hypoplasia of the external condyle of the femur are noted. The flow is divided into recurrent and persistent. Persistent include habitual (the patella dislocates during normal movements of K. s.) 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 paid attention only after the child has begun to walk. Treatment for a mild degree of dislocation of the patella is conservative. It is aimed at restoring the balance between the outer and inner wide muscles of the thigh. Assign therapeutic exercises, massage, electrical stimulation. The use of devices that fix the patella, as a rule, is not very effective. With more severe degrees of congenital dislocation of the patella, operative. The forecast concerning function To. page. favorable with timely treatment.

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

Damage. Most often meets To. the page which is followed by limited hemorrhage in a periarticular fatty tissue. Patients complain of pain that increases with movement. Local swelling is determined by palpation. patellar ligaments may be accompanied by hemorrhage in the subpatellar synovial bursa (bursitis), bruising of the patella - in the prepatellar (prepatellar bursitis). In these cases, bulging of the corresponding bag and its fluctuation are noted, and active extension of the lower leg is often weakened. Treatment is carried out on an outpatient basis. Showing cold on the knee joint; apply a pressure bandage for 2-3 days, then prescribe thermal procedures and exercise therapy. Quite often bruised To. combined with hemorrhage in his cavity - hemarthrosis. It occurs when the integrity of the vessels of the synovial membrane is violated, damage to the articular capsule, ligaments, cartilage ( 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 lower leg is bent, bulges appear on both sides of the patellar ligament, the range of motion is not limited, the volume of blood that has poured into the joint cavity is not more than 15 ml; II degree - pain diffused throughout the joint, aggravated by movement, the contours of the joint are significantly smoothed, its circumference exceeds the circumference of a healthy joint by 2-3 cm, there is a symptom of balloting of the patella, 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 and more, movements are sharply limited, the amount of blood in the joint is 100 ml and more. With hemarthrosis of the II degree, the local temperature may increase, and with the III degree - also. In addition, with a pronounced hemarthrosis, pain contracture can be observed - the lower leg is set in a flexion position. Grade II is usually noted with damage to the articular cartilage, meniscus, capsule and ligaments. III degree - with intra-articular fractures, fracture-dislocations and dislocations. The diagnosis of hemarthrosis II and especially III degree in the acute period is difficult. The patient is put on a transport splint and taken to a trauma center, where a joint puncture is performed to evacuate blood, and an X-ray of the joint is performed to detect fractures. In order to clarify the diagnosis in a specialized hospital, arthroscopy can be used. With hemarthrosis of the I degree, the bruised area is irrigated with chloroethyl, a pressure bandage is applied, puncture is usually not performed. With hemarthrosis of the II degree is mandatory (sometimes repeated). After removal of blood, about 20 ml 1-2% novocaine solution. Within 7-10 days, the joint is shown with a plaster splint or splint, then physiotherapy, exercise therapy are prescribed. The knee joint usually fully recovers after 1 month. Sometimes post-traumatic recurrent develops ( post-traumatic serous), the cause of which is most often undiagnosed or unrepaired intra-articular damage. Treatment of synovitis includes puncture of the joint to remove the effusion, immobilization of the limb for several days, and the use of desensitizing agents. Assign therapeutic exercises (without load along the axis of the lower limb), massage, electrical stimulation of the thigh muscles. With a small amount of effusion, compresses of medical bile on K. page, dimexide, hydrocortisone are recommended. In case of recurrence, it is administered intra-articularly (see Arthritis) .

Ruptures of the capsule and ligaments of the knee joint are common. Distinguish full and partial sheaves To. They occur with movements that exceed physiological limits. Thus, the tibial and peroneal collateral ligaments are usually torn when the tibia is excessively abducted or adducted. the anterior cruciate ligament can occur when a force is applied to the posterior surface of the half-bent tibia, especially if it is combined with rotation, and the posterior cruciate ligament can occur when the tibia is sharply overextended or a strong blow is applied to its anterior surface. are damaged at the place of their attachment to the bones that form the joint, sometimes a bone fragment occurs. throughout the ligament there are complete, partial and intra-stem (for example, the anterior cruciate ligament; rice. 17-19 ). The most susceptible to injury is the tibial collateral ligament ( rice. twenty ), the integrity of the anterior cruciate is less often violated. Both of these ligaments and the internal one are often damaged - the so-called unfortunate triad, or Turner's triad. Ruptures of the peroneal collateral ligament can often be accompanied by damage to the peroneal nerve, often simultaneously disrupting the integrity of the anterior cruciate ligament and the external meniscus. Simultaneous damage to all cruciate and collateral ligaments and structures of the extensor apparatus of the lower leg (tendon of the quadriceps muscle or patellar ligament) is the most severe type of damage to the ligamentous apparatus of the knee joint.

In the acute period, ruptures of the ligaments To. with, combined with severe pain, hemarthrosis of II-III degree, reactive synovitis (see. Synovial bags) . Note the smoothness of the contours of the joint, a positive symptom of balloting the patella. However, with an extensive rupture of the joint capsule and blood entering the paraarticular tissues, this symptom may be absent. According to the location of paraarticular hemorrhages, the localization of damage to the ligamentous apparatus of the joint is judged. So, a rupture of the tibial collateral ligament is usually accompanied by the formation of an extensive subcutaneous hematoma over the entire inner surface in the K. s. area, and damage to the posterior cruciate ligament and associated ruptures of the posterior part of the capsule are manifested by swelling and hematoma in the popliteal region. Any damage to the ligaments To. causes severe dysfunction of the entire lower limb.

Of great importance in recognizing damage to the ligamentous apparatus are special diagnostic techniques - the so-called stability tests, which usually consist in a careful passive reproduction of the damage mechanism. for example, with a complete rupture of the tibial collateral ligament, an increase in the amplitude of passive abduction of the lower leg and its rotation outward is noted, if the integrity of the anterior cruciate ligament is violated, the lower leg is displaced forward (a symptom of the anterior drawer), if the posterior cruciate ligament is damaged, the lower leg is displaced backward (a symptom of the posterior drawer ). According to the magnitude of the deviation or displacement of the lower leg, the degree of damage to the ligamentous-capsular apparatus is estimated. 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 on the inner surface of the K. s., I degree; II degree - an incomplete rupture with a slight divergence of the ends of the ligament, characterized by a more pronounced pain syndrome, hemarthrosis of the II degree, diastasis between the ends of the torn ligament, an increase in the deviation of the lower leg outward by more than 10-15 ° and expansion of the internal part of the joint space on radiographs by more than 8-10 mm; III degree - a complete rupture of the ligament fibers with a divergence of their ends, usually combined with damage to other capsular-ligamentous structures and cartilage.

The diagnosis of damages of the capsular and copular device To. in the acute period in the presence of hemarthrosis is difficult. In this regard, it is previously removed from the joint cavity (diagnostic puncture) and about 20 ml 1% solution of novocaine, which helps to eliminate pain contracture and relax muscles. To clarify the diagnosis, radiography, arthrography, and ultrasound are performed. In some cases, arthroscopy is performed.

Treatment of acute ruptures of the capsular-ligamentous apparatus To. depends on the degree of damage. So, with I-II degree in the first days, a 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. With severe hemarthrosis, a puncture of the joint (sometimes repeated) is necessary. Complete ligament ruptures (grade III) are an indication for surgery, after which a plaster cast is applied for up to 6 weeks. To prevent significant hypotrophy of the muscles surrounding the joint, therapeutic exercises (isometric muscle tension), electrical stimulation of the thigh muscles are prescribed from the first days. After the cessation of immobilization, exercise therapy, massage, are shown. The function of the joint is usually restored no earlier than after 6-8 months. after operation. The prognosis is usually favorable, sometimes a persistent contracture is formed (with improper postoperative treatment). In some cases, especially after repeated injuries of the composition, post-traumatic osteoarthritis progresses rapidly until its functions are fully restored, recurrent synovitis and post-traumatic joint instability are noted. Depending on the nature of the displacements of the lower leg, which are caused by the functional inferiority of the capsular-ligamentous apparatus of the joint and muscles, there are anteromedial (anterointernal), anterolateral (anterior external), 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 disrupts the supporting and locomotor functions of the lower limb. Treatment for a mild degree of post-traumatic instability is often conservative - therapeutic, aimed at strengthening the muscles that prevent pathological displacements of the lower leg, massage, wearing a special knee pad. The expressed instability To. can only be removed promptly. For this purpose, intra-articular autoplastic or alloplastic (for example, lavsanoplasty of the K. 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. Of great importance for the restoration of joint function is the early appointment of therapeutic exercises, massage and physiotherapy. Support 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 tendon of the quadriceps femoris and patellar ligament) are clinically manifested by a violation of the active extension of the lower leg in the absence of an obstacle to the passive execution of this movement. There are complete and partial ruptures. Palpation can usually be determined at the site of the gap. For a complete rupture, the absence of active extension of the lower leg is characteristic, for a partial one, its more or less pronounced weakening (it is possible only under facilitated conditions, for example, in the supine position). Ultrasound is used to clarify the diagnosis. With a complete rupture of the ligament of the patella, due to the traction of the muscle, it rises up (proximally), which can be detected by palpation and on radiographs. Treatment of partial ruptures of the extensor apparatus of the lower leg is conservative - overlay for 3 weeks. gypsum splint for K. s., exercise therapy, massage, physical exercises in the water. With 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), accompanied by very serious consequences (disturbance of the lower limb sporosity, joint stability, damage to blood vessels and nerves). There are open and closed dislocations; in the direction of displacement of the bones of the lower leg, they are divided into anterior, posterior. external, internal and rotational (posterior-external dislocations are more common). In some cases, tissue is marked, which makes the dislocation irreducible. With any type of dislocation, the joint capsule, menisci, and ligamentous apparatus are damaged. Clinically defined bayonet curvature of the lower limb and its shortening. Flexion and extension of the lower leg is usually not possible, but lateral movements are preserved. In all cases, hemarthrosis of the III degree occurs, very often it is disturbed in the lower leg and foot. Palpation determines the protruding condyles of the femur (with posterior dislocation) or the tibia (with anterior dislocation). To clarify the diagnosis, an x-ray is performed. Treatment of dislocations with tissue interposition is operative. In most cases, closed dislocations are eliminated under general anesthesia by 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 spa treatment is carried out. recovers in 10-12 weeks. Quite often after dislocation the resistant contracture or (at the early beginning of movements) instability is formed To. page. (so-called total instability). To eliminate chronic dislocations of the lower leg, the Volkov-Oganesyan hinge-distraction apparatus is used.

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

Damage to the menisci of the knee joint - see Articular menisci . Many injuries of the capsular-ligamentous apparatus To. combined with various meniscal tears, for example, Turner's triad, dislocations of the lower leg.

Cartilage damage K. s. may be isolated or combined with other intra-articular lesions. The so-called (softening of the cartilage) or transchondral (for example, as a result of impression on a strictly localized area) 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. So, with chondromalacia of the patella, patients complain of pain along the anterior surface of the patella, which increases after a long stay in a sitting position with a bent knee, a crunch when the patella moves, increased pain when tapping on the patella, synovitis, and intermittent blockades. To clarify the diagnosis, they are transported, which often does not work. K. s. allows you to recognize damage to the cartilage and to carry out surgical treatment of the damaged area of the articular surface, such as the affected area of cartilage.

Among the fractures of the bones forming To. pages, most often meet a patella. There are transverse ( rice. 21 ), longitudinal, stellate and multicomminuted fractures. Clinically, these fractures resemble other injuries of the extensor apparatus of the lower leg. It is of decisive importance for establishing a diagnosis. The treatment of fractures without displacement is conservative, and if the bone fragments diverge, it is surgical (). The patella is unacceptable even with its comminuted fracture, tk. in this case, the extensor of the lower 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 lower leg. There are isolated fractures of the condyles without displacement and with displacement more often upwards or upwards 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 osteoepiphyseolysis are noted, in these cases it can shift anteriorly ( extensional) 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, an x-ray is performed.

Acquired contractures To. can be flexion and extensor. They occur early after an injury as a result of a pain reaction (reflex contracture, false), after prolonged immobilization of the joint, improper rehabilitation treatment, etc. In terms of up to 3 months. after injury, treatment is often conservative: with persistent arthrogenic contractures, it is indicated - ilio-tibial tract, lengthening of the quadriceps femoris muscle, arthrotomy with mobilization of the patella and extensor of the leg.

II Knee-joint

trochlear joint formed by the condyles of the femur, the articular surfaces of the tibia and the patella. On the front surface of the joint is the patella (patella). The tendon of the quadriceps femoris muscle is attached to it, 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 are two crescent-shaped cartilages - the inner and outer menisci. The entire knee joint is enclosed in an articular bag. It has several protrusions - inversions, synovial bags and folds containing adipose tissue. The anterior section of the articular capsule is formed by the tendon of the quadriceps muscle. K. s. reinforced by a ligamentous apparatus, which consists of lateral and cruciate ligaments. The main movements in the knee joint are flexion and extension.

The reason for first aid, as a rule, are various injuries of the knee joint. With most joint injuries, blood is poured into its cavity, which accumulates in torsion or synovial bags. As a result, the shape of the joint changes - its relief is smoothed to varying degrees (the joint swells), its volume increases, pain appears, which increases with movements and muscle tension. In severe intra-articular injuries, hemorrhage (hemarthrosis) is detected shortly after the injury, it grows rapidly, the joint seems to swell from the inside. In milder injuries, such as a bruise, hemarthrosis may appear after a few hours or even the next day. in 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 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 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, tk. hemorrhage into the joint may be associated with damage to the menisci, ligaments, dislocation of the patella, fractures of the articulating bones.

From torn ligaments To. more common injury to the medial lateral ligament ( rice. 1, a ). At the same time, damage to the meniscus can occur. With a complete rupture of the ligament, pain in the joint is noted, the lower leg is easily retracted to the side. With its partial damage, the deviation of the lower leg to the side is less pronounced. into the joint cavity is usually greater than after a bruise. There is often also bruising on the inside of the joint. anterior cruciate ligament of the knee ( rice. 1, b ) occurs more often in people who are actively involved in sports. Often this damage is combined with an injury to the internal lateral ligament and meniscus. As a rule, it occurs as a result of a sharp turn and deviation of the lower leg outward. Sometimes the victim hears a crack, then pain in the joint is noted, it begins to swell, because. blood flows into his cavity. First aid includes immobilization of the joint, the injured leg should not be stepped on, because. load may cause additional injury. The extremities during long-term transportation are given an elevated position and cold is applied to the joint. Any suspicion of damage to the ligaments To. is an indication for transporting the victim to a specialized hospital for examination by a traumatologist and additional examination.

Damage to the menisci K. s. immediately after the injury differ little from his other injuries. In some cases, due to the infringement of the torn part of the meniscus that has shifted in the joint cavity, mobility in it is limited, that is, the so-called appears. In this case, you should not try to forcibly eliminate it, because. you can further damage the meniscus or adjacent intra-articular structures. 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.

Dislocation of the patella and dislocation of the lower leg can occur in the knee joint ( rice. 2 ). In the first case, the patella is displaced (more often outward) in the position of the leg half-bent at the knee when the thigh is rotated inwards. As a rule, the reduction is performed without much difficulty by the victim himself, moving the patella with his hands into place. 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 bandage is applied. In the absence of immobilization after reduction of the dislocation of the patella, a habitual dislocation may subsequently develop.

Dislocation of the lower leg is a very serious injury. More often it is displaced posteriorly (posterior dislocation) or posteriorly and outwardly (posteriorly external dislocation). With a posterior dislocation, the vessels running in the popliteal region are often damaged, and with a posterior dislocation, the peroneal nerve. A characteristic sign of dislocation is a change in the form of K. s. after injury and the impossibility of movements in it. This dislocation must be urgently eliminated, but you should not try to do this without general anesthesia. immobilize with a splint (better than the Dieterichs type) or with the help of improvised means (see Thigh). In case of circulatory disorders in the lower leg and foot, if long-term transportation is ahead, you can try to reduce the displacement, which is the cause of vascular compression, before applying the splint. To do this, very carefully and slowly pull the foot along the longitudinal axis of the leg and slightly squeeze the lower leg in the direction opposite to its displacement. You should not make great efforts, because. this can cause additional injury and aggravate circulatory disorders.

Fractures of the bones forming To. pages also belong to 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, there is swelling of the joint, extensive, pain during movement and palpation. As a rule, the victim himself cannot straighten the leg at the knee joint, and with outside help this can be done without difficulty. With the divergence of fragments of the patella, it is possible to determine the retraction between them. First aid involves immobilizing the knee joint in full extension using a standard splint or using improvised means. Unlike most joint injuries, after immobilization, the victim can start on this leg.

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

At open damages To. a sterile dressing is applied to the wound. If it is small and does not penetrate into the joint cavity, then this can be limited, but if the capsule, ligaments, dislocations or fractures are damaged, the joint should be immobilized with a splint. With open injuries penetrating 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) enter the joint cavity, a sterile bandage is also applied to the wound, and the joint is immobilized in the position in which it is in first aid. You should not try to extract it, even if at first glance it is located under the skin and it seems that this is possible without great difficulty, because. without special wound treatment, 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 too tight.

Bandages when rendering first aid, bandages are often applied to the knee joint; with small superficial wounds and abrasions, a mesh or adhesive plaster is often used. From bandage bandages (Bandages), a so-called turtle bandage is usually applied to this joint ( rice. 3 ). The first round of the bandage is carried out through the area of the patella, then the tours of the bandage diverge up (on the thigh) and down (on the lower leg), each time crossing behind (under the knee). The so-called converging tortoise 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 on the knee joint if it is half-bent, and on a straightened leg, use a figure-of-eight bandage. A kerchief bandage is also convenient ( Atlas of human anatomy- View from above. tibial tuberosity; transverse ligament of the knee; anterior menisco-femoral ligament; lateral meniscus; anterior cruciate ligament; posterior menisco femoral ligament; posterior cruciate ligament; medial meniscus... Atlas of human anatomy

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

Damage specifics

How is the treatment carried out?

Medical assistance

Physiotherapy

Manual therapy

Folk methods of treatment

Posterior cruciate ligament (PCL) injuries

Injuries to the internal lateral ligament

Damage to the external lateral ligament

Patellar tendon injury

Patellar Retainer Injuries

Literature

The reasons

Classification

Symptoms

Diagnostics

Treatment

Pathogenesis

Clinical manifestations and complications

Treatment

Knee joint (normal anatomy in axial view)

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Treatment of dislocation of the patella of the knee joint in Germany

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Dr. Peter Angele

Patella Injury: Symptoms and Causes

Treatment of injuries of the patella of the knee joint

Surgical treatment for fracture of the patella

Medial Patella Retainer

Classification according to the direction of displacements:

Risk factors:

Patella Dislocation Treatment

Treatment of damage to the medial meniscus of the knee joint

Damage specifics

How is the treatment carried out?

Medical assistance

Physiotherapy

Operation

Manual therapy

Folk methods of treatment

KSS. Pathology of the patellofemoral joint (PFJ)

medial side

Lateral side

Biomechanics

Anamnesis

Physical examination

X-ray studies

Conclusion

Literature