INDICATIONS FOR SURGERY: Complete tear; associated meniscal pathology Well motivated person who will do the rehab program; physiologically young Unwilling to change lifestyle; job and sports require twisting, cutting Minimal evidence of DJD
WHEN TO DO SURGERY : Wait at least 3-4 weeks after injury Decrease the swelling Decrease Quad inhibition Decrease hamstring overfiring Decrease scarring Increase ROM; decrease stiffness
SURGERIES PERFORMED 1.Bone-tendon-bone with middle 1/3 of patellar tendon 2.Semitendinosis and gracilis: fold them in ½ so have a 4 tendon bundle 3.Allograph: bone-tendon-bone patellar tendon from cadaver Key in surgery is correct isometric placement of the graph.
80-90% of patients have a good result with surgery going back to previous levels of activity. Some complications that may arise and give a less than favorable result are: Patellar tendonitis Patellofemoral pain/chondromalacia Limited ROM at extremes; loss of even a few degrees of terminal extension is a problem Stretching out of graph
The patella must have balanced muscular forces around it to ride properly in the femoral groove. The VMO should fire before the VL. The VMO/VL ratio should be 1:1 Tight ITB, hamstrings and calf can disrupt muscular balance.
OTHER FACTORS CAUSING PFPS: 1.Overpronation 2.Anteversion 3.Weak Hip ER & ABD 4.Tibial Varum 5.Increased Q angle
Complains of pain on knee flexion May complain of snapping Pain gets worse on ROM from full flexion to full extension. Often result of: genu varum; over pronation; femoral anteversion; spinal problems.
ADMINISTRATION ORAL: Used in tx of diseases which affect multiple joints; Dose pack for chronic musculoskeletal problems LOCAL INJECTION: Used for tendinitis, bursitis, fasciitis TOPICAL USE: Dermatologic effects only
SIDE EFFECTS: ORAL Osteoporosis: pathologic fractures Avascular Necrosis Disturb fat and carbo metabolism: increase risk of diabetes; increased fat distribution in trunk and face Hypertension due to NA and H20 retention Steroid myopathy Steroid psychosis
SIDE EFFECTS: LOCAL INJECTION No systemic effects False sense of recovery Local tendon/muscle atrophy: rupture Skin changes
ANALGESICS Allow early initiation of rehab Improve quality of life for persons with chronic pain Allow patients to tolerate surgery
NON-NARCOTIC Acetaminophen: Has central nervous system effect through cental inhibition of prostaglandins Aspirin: Has peripheral effect through peripheral inhibition of prostaglandins NSAIDS: Have analgesic effect on nervous system as well as decreased inflammation
NARCOTIC Common property: bind to opioid receptors in brain Results in significant elevation of pain threshold; can be addictive
INDICATIONS Mild/moderate musculoskeletal pain: non- narcotics; acetaminophen first choice; NSAIDS may be more logical if inflammation is causing pain, ie acute injuries and inflammatory arthritis Osteoarthritis: acetaminophen Chronic musculoskeletal pain: acetaminophen
Continued…… Acute postoperative pain: narcotics; can be given IV or IM Chronic, Severe pain: narcotics See Table 3 for commonly used analgesic drugs
SIDE EFFECTS ACETAMINOPHEN: generally safe; liver toxicity ASPIRIN/NSAIDS: as previously covered NARCOTICS: respiratory suppression; sedation, nausea and vomiting; urinary retention; euphoria/dependence
ANTIBIOTICS Used to treat or prevent bacterial infections which can occur postoperatively or post compound fracture Classified based on chemical structure and effectiveness against certain bacteria (Table 4)
INDICATIONS FOR USE Use drug best suited to fully eradicate the bacteria causing the infection Infection must be cultured to determine what kind it is Sometimes used prophylactically at time of surgery; mostly with patients with compromised immune system Always used with patients with open fractures