1. Miscellaneous knee problems

2. Osteochondritis dissecans (splitting O.ch. of the knee):

3. its suggested to be caused by repeated trauma by the edge of the patella on full flexion that occurs on the lateral aspect of the medial femoral condyle (this site accounts for more than 80% of all cases). its suggested to be caused by repeated trauma by the edge of the patella on full flexion that occurs on the lateral aspect of the medial femoral condyle (this site accounts for more than 80% of all cases).

4. The disease pass in three stages: 1. Avascular nonseperated segment with intact overlying cartilage. 2. Detached Undisplaced segment. 3. Displaced segment, either incomplete or complete where it acts like a loose body leaving an ulcer called crater that later get fibrosed.

6. Clinical features: Adolescent patient mainly males 15-20 years of age, it can be bilateral & may run in families. Adolescent patient mainly males 15-20 years of age, it can be bilateral & may run in families. There is intermittent pain, swelling, givingway & locking together with muscle wasting. There is intermittent pain, swelling, givingway & locking together with muscle wasting.

7. Diagnostic features are: 1. Tenderness on medial femoral condyle. 2. Positive Wilson’s test; with the knee flexed we try internal rotation & gradual extension; this will induce medial condyle pain which get relieved on external rotation.

8. Diagnosis X-ray: X-ray: It’s helpful at later stages. While isotope scanning and MRI can diagnose it earlier. Arthroscopy: can prove diagnosis & sometimes used for treatment. Arthroscopy: can prove diagnosis & sometimes used for treatment.

10. Differential diagnosis: 1. Avascular necrosis of the medial fernoral condyle that occurs in older alcoholics or in steroid abuse, it affect the dome of the condyle & is more extensive. 2. Osteochondral fracture of the femoral codyle.

11. Treatment In early stages the lesion is stable, here restriction of activities with the use of caliper or crutch for 6-12 months is useful and no need for other treatment, intimate follow up & MRI of the other knee is indicated. In early stages the lesion is stable, here restriction of activities with the use of caliper or crutch for 6-12 months is useful and no need for other treatment, intimate follow up & MRI of the other knee is indicated.

12. Treatment At later stages & if the fragment is small it can be removed. At later stages & if the fragment is small it can be removed. If its more than one centimeter & not detached we fix the fragment in position. If its more than one centimeter & not detached we fix the fragment in position. If the fragment is detached with unhealthy crater, it’s removed & the crater is drilled to allow healing with fibrocartilage. If the fragment is detached with unhealthy crater, it’s removed & the crater is drilled to allow healing with fibrocartilage.

13. Synovial chondromatosis

14. Rare disorder in which the tips of the synovial sheath undergoes cartilaginous metaplasia & later detaches as a free cartilaginous loose bodies Rare disorder in which the tips of the synovial sheath undergoes cartilaginous metaplasia & later detaches as a free cartilaginous loose bodies

16. Clinical features: Chronic swelling, givingway, locking & pain are common. Chronic swelling, givingway, locking & pain are common.

17. X-ray:it may show loose bodies. Arthroscopy:can prove the diagnosis (snowstorm appearance).

18. Treatment: By athrotomy or arthroscopy, all those loose bodies must be washed out and removed & the abnormal synovium is excised (synovectomy). By athrotomy or arthroscopy, all those loose bodies must be washed out and removed & the abnormal synovium is excised (synovectomy).

19. Loose bodies inside the knee

20. Causes: 1. Post-traumatic osteochondral fracture. 2. Fractured ostephytes in cases of osteoarthritis of the knee joint. 3. Osteochondritis dissecans. 4. Synovial chondromatosis. 5. Charcot’s (neuropathic) joint.

21. Clinically they cause aches, swelling, locking & givingway. Diagnosis by X-ray, MRI, and arthroscopy. Treatment by removal of the loose bodies & treatment of the cause.

22. Swelling of the knee joint

25. 1st. heamarthrosis: by; 1. Hemophilic arthropathy. 2. Post-traumatic by; a. Intraarticular fracture a. Intraarticular fracture b. Rupture of ACL or capsule. b. Rupture of ACL or capsule. c. Rupture or damage of the synovial membrane. c. Rupture or damage of the synovial membrane. Clinical features, diagnosis & treatment all according to the cause. Clinical features, diagnosis & treatment all according to the cause.

26. 2nd. Acute septic arthritis: Causes, pathology, C/F, investigations, differential diagnosis & treatment all are previously discussed. Causes, pathology, C/F, investigations, differential diagnosis & treatment all are previously discussed. Special point is that sometimes- repeated aspiration by wide bore needle or cannula & trocher is used in the knee together with saline irrigation, all under antibiotic cover. If this fails we still can do open arthrotomy and drainage. Special point is that sometimes- repeated aspiration by wide bore needle or cannula & trocher is used in the knee together with saline irrigation, all under antibiotic cover. If this fails we still can do open arthrotomy and drainage.

27. 3rd. Acute post-traumatic synovitis: Synovial fluid collects few hours after injury or in the next day, this is associated with Q-wasting & painful limitation of movements. Sometimes it needs aspiration & resting the joint in POP. Synovial fluid collects few hours after injury or in the next day, this is associated with Q-wasting & painful limitation of movements. Sometimes it needs aspiration & resting the joint in POP.

28. 4th. Acute non-traumatic synovitis: Acute swelling without trauma or infection suggests crystal deposition disease as Gout or Pseudogout; this may need aspiration & biochemical study. Acute swelling without trauma or infection suggests crystal deposition disease as Gout or Pseudogout; this may need aspiration & biochemical study.

29. 5th. Chronic knee swelling: as with; 1. Tuberculosis. 2. Rheumatoid arthritis. 3. Osteoarthritis. 4. Pigmented villonodular synovitis. 5. Charcot’s disease (neuropathic joint).

30. Osteoarthritis of the knee (OA): Knee is commonly involved by OA, which can be secondary or most commonly primary OA that usually affect people after 5Oyears and mostly occurs bilaterally. Knee is commonly involved by OA, which can be secondary or most commonly primary OA that usually affect people after 5Oyears and mostly occurs bilaterally.

31. Clinical features: Special features include; Bow legs (Genu varus) its very common. Bow legs (Genu varus) its very common. Pain on varus or valgus stress of the knee in the affected joint compartment Pain on varus or valgus stress of the knee in the affected joint compartment On knee movement PF-crepitus may be reproduced. On knee movement PF-crepitus may be reproduced.

32. X-ray: All previously mentioned cardinal features are seen with special features like; 1. Features mostly seen in the medial compartment. 2. There is varus alignment between tibia & femur. 3. Picture better seen in the standing films.

33. Treatment : Conservative treatment? Conservative treatment? Operative treatment Operative treatment

34. Operative treatment 1. Arthroscopic washout; to decompress the joint &wash the proteolytic enzymes & loose bodies. 2. Patellectomy. 3. Realignment osteotomy; to correct varus deformity we do wedge resection valgus osteotomy of the upper tibia, this acts by Redistribution of weight towards more healthy areas of the articular cartilage.Redistribution of weight towards more healthy areas of the articular cartilage. Venous decompression to decrease pain.Venous decompression to decrease pain. Correct deformity.Correct deformity.

35. Operative treatment 4. Replacement arthroplasty. 5. Arthrodesis.

36. Swellings around the knee joint: 1) Prepatellar bursitis 2) Infrapatellar bursitis 3) Semimembranosus bursa 4) Popletial cyst 5) Popletial-artery aneurysm.

37. Swellings around the knee joint: 6) Meniscal cyst. 7) Ganglion. 8) Calcified deposits of collateral ligament. 9) Prolapsed torn meniscus. 10) Tumors like; lipoma, fibroma or osteochondroma.

38. Prepatellar bursitis; There is inflammation of the bursa between the skin & the patella, the condition called house-made knee. The joint is normal but there is swelling of the bursa sometimes its tender, it may need aspiration & steroid injection or sometimes surgical excision. Always exclude rheumatoid & gouty arthritis. There is inflammation of the bursa between the skin & the patella, the condition called house-made knee. The joint is normal but there is swelling of the bursa sometimes its tender, it may need aspiration & steroid injection or sometimes surgical excision. Always exclude rheumatoid & gouty arthritis.

40. Infrapatellar bursitis; It’s inflammation of the bursa between the skin & the patellar ligament, its also called clergyman’s knee. It’s inflammation of the bursa between the skin & the patellar ligament, its also called clergyman’s knee.

41. Semimembranosus bursa; Swelling of the bursa between the semi-membranosus tendon & the medial head of gastrocnemious muscle appears as a painless swelling on the posteromedial aspect of the knee, its fluctuant & gets larger when the knee is straight and decrease or disappear as the knee is flexed. If it’s symptomatic it needs surgical excision. Swelling of the bursa between the semi-membranosus tendon & the medial head of gastrocnemious muscle appears as a painless swelling on the posteromedial aspect of the knee, its fluctuant & gets larger when the knee is straight and decrease or disappear as the knee is flexed. If it’s symptomatic it needs surgical excision.

42. Popletial cyst (backer’s cyst): It’s a type of synovial fluid filled cystic swelling herniates posteriorly from the knee joint, its most common in OA of the knee and also in some cases of rheumatoid arthritis. Its painless fluctuant & at the level of the joint it does not affected by the knee movements. Treatment, always treat the cause specially OA as by high tibial osteotomy, which usually lead to cyst regression. Sometimes we do aspiration & local steroid injection or surgical excision of the cyst but those procedures usually associated with recurrence of the cystic swelling. It’s a type of synovial fluid filled cystic swelling herniates posteriorly from the knee joint, its most common in OA of the knee and also in some cases of rheumatoid arthritis. Its painless fluctuant & at the level of the joint it does not affected by the knee movements. Treatment, always treat the cause specially OA as by high tibial osteotomy, which usually lead to cyst regression. Sometimes we do aspiration & local steroid injection or surgical excision of the cyst but those procedures usually associated with recurrence of the cystic swelling.