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Indications

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Indications

indica

Uploaded by

Đỗ Quỳnh Như
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Indications

OCD = displaced cartilage


congenital slipped patella = flattening/underdevelopment of lateral femoral condyle
hemophilia = intercondylar widening
intercondylar fossa pathology = loose bodies
Critique
superimposition of patella + ipsilateral femoral condyle
asymmetrical tibiofemoral joint spaces
NORMAL FINDINGS
Normal anatomy

Normal variants
fabella
sesamoid bone in lateral head of gastrocnemius
best seen on lateral view
cyamella
sesamoid bone in popliteus tendon
usually present in lateral aspect of distal femur in popliteal groove
best seen on AP view
cortical desmoid
cortical lucency in posteromedial aspect of distal femur
represents origin of medial head of gastrocnemius + insertion of adductor magnus
seen in adolescents (10-15 yo)
bipartite/tripartite patella
usually superolateral with smooth margins
CLINICAL PEARLS
Knee OA
Classification = Kellgren & Lawrence
Kellgren & Lawrence (based on AP weightbearing XRs)
Grade 0 • no joint space narrowing (JSN) or reactive changes
Grade 1 • possible osteophytic lipping + doubtful JSN
Grade 2 • definite osteophytes + possible JSN
Grade 3 • moderate osteophytes + definite JSN + some sclerosis + possible bone end
deformity
Grade 4 • large osteophytes + marked JSN + severe sclerosis + definite bone end deformity
Recommended views
weightbearing AP
weightbearing lateral
semi-flexed 45° PA
most sensitive for early joint space narrowing (JSN)
tangential
Findings
joint space narrowing (JSN)
osteophytes
eburnation of bone
subchondral sclerosis/cysts
TKA templating
AP/PA view
for true assessment, need full-length scanogram view (can be fooled by standard AP/PA view)
assess mechanical axis of limb
line from the center of femoral head to center of talus
neutral = bisects knee
varus = passes medial to center of knee
valgus = passes lateral to center of knee
important because restoration of neutral axis distributes weight-bearing loads equally to minimize risk
+ aseptic loosening
determine extent of coronal deformity
tibiofemoral angle
angle between AAF + AAT
normal 7° ± 1° valgus
hip-knee-ankle angle
angle between MAF + MAT
normal 0°
determine femoral resection angle
MAF – AAF
normal varies by individual
important because >7° valgus leads to increased Q angle, which can lead to patellofemoral maltrackin
determine tibial bone cut
line perpendicular to MAT
thickness of cut is determined by thickness of the tibial components
important to place cut at level of pre-arthritic tibial plateau because:
elevating joint line > 8mm --> mid-flexion instability, patellofemoral maltracking, pseudopatella baja lea
increased force at patellofemoral joint + extensor mechanism dysfunction
lowering joint line --> flexion instability, extension lag, patellar subluxation, retropatellar pain
Lateral view
determine tibial slope
angle between line along articular surface of tibia + line perpendicular to anterior cortex of tibia
normal 5-15°
in cruciate retaining knee typically maintain close to native slope (~5-7°)
too much slope can lead to flexion/AP instability
too little slope can lead to overstuffing of the flexion gap and limited ROM
if using PS implant aim for 0-3° slope
less slope needed as removal of the PCL opens the flexion gap
avoid CAM/post impingement
assess for presence of patella baja
requires lateral XR with knee in 30° flexion
calculate Insall-Salvati ratio
ratio of patellar tendon length to patellar bone length
patella baja if < 0.8
important because presence of patella baja can make exposure more difficult and cause decreased RO
impingement
assess for history of patellectomy
important because can lead to loss of extension strength and overload PCL
consider using PS or dished CR implant for optimal outcomes

Sunrise/Tangetial view
determine patellar shift
distance between apex of lateral femoral condyle + lateral edge of patella
normal 0mm
determine patellar tilt
angle between line drawn along femoral condyles + lateral facet of patella
normal > 12°
TKA periprosthetic fracture
Classification
distal femur
Lewis & Rorabeck
Lewis and Rorabeck Classification (1997)
Type I Nondisplaced; component intact
Type II Displaced: component intact
Type III Displaced; component loose or failing
Su
Su and Associates' Classification of Supracondylar Fractures of the Distal Femur
Type I Fracture is proximal to the femoral component
Type II Fracture originates at the proximal aspect of the femoral component and extends
proximally
Type III Any part of the fracture line is distal to the upper edge of anterior flange of the
femoral component
proximal tibia = Felix

Felix and Associates' Classification of Periprosthetic Fractures of the Tibia Associated


with TKA
Type I Fracture of tibial plateau
Type II Fracture adjacent to tibial stem
Type III Fracture of tibial shaft, distal to component
Type IV Fracture of tibial tubercle
o
patella = Goldberg
Goldberg Classification
Type I Fracture not involving implant/cement interface or quadriceps mechanism
Type II Fracture involving implant/cement interface and/or quadriceps mechanism
Type III Type A: inferior pole fracture with patellar ligament rupture
Type B: inferior pole fracture without patellar ligament rupture
Type IV All types with fracture dislocations
Recommended views
AP
lateral
consider CT scan for better delineation of fracture pattern and proximity to implant
Treatment criteria
distal femur
nonoperative treatment acceptable if nondisplaced fractures with stable prosthesis
retrograde IMN if
intact/stable prosthesis with open-box design to accommodate nail
fracture proximal to femoral component (Su Type I)
fracture that originates at the proximal femoral component and extends proximally (Su Type II)
ORIF with fixed angle device if
intact/stable prosthesis
Lewis-Rorabeck II or Su Types I or II (described above) unable to accommodate intramedu
fracture distal to flange of anterior femoral component (Su Type III)
revision to long stem prosthesis if
loose femoral component
Lewis-Rorabeck III or Su Type III (described above) with poor bone stock
distal femoral replacement if elderly patients with loose (Su type III) or malpositioned comp
poor bone stock
proximal tibia
nonoperative treatment acceptable if nondisplaced fracture with stable prosthesis
ORIF if unstable fracture with stable prosthesis
long-stem revision prosthesis if displaced fractures with loose tibial component
patella
nonoperative treatment acceptable if
stable implants with intact extensor mechanism
non-displaced fractures
ORIF vs. revision arthroplasty vs. patellectomy if
loose patellar component
extensor mechanism disruption
TKA aseptic loosening
Recommended views
AP
tibial osteolysis readily visible on AP
femoral osteolysis may be difficult to detect on AP as lesions are typically located in posterior condyles
obscured by the femoral component
lateral
helpful for identifying femoral osteolysis
good quality lateral view is critical
oblique
often more helpful for identifying femoral osteolysis
Findings
radiolucent area around implant or cement with sclerotic border
especially radiolucencies > 2 mm
change in position of the implant
varus or valgus subsidence of tibial component
progressive widening of cement-bone or bone-prosthesis interface
cement cracking or fragmentation
Treatment criteria
nonoperative treatment acceptable if stable implant with minimal symptoms
revision TKA if
pain due to aseptic loosening
pain with evidence of osteolysis
extensive osteolysis that would compromise revision surgery in the future
TKA instability
Classification
extension = varus/valgus instability
flexion = AP, occurs when the flexion gap exceeds the extension gap
mid-flexion = malrotation when the knee is flexed between 45 and 90 degrees
global = laxity of both flexion and extension gaps, as well as varus/valgus instability
genu recurvatum = fixed valgus deformity and iliotibial band contracture
Recommended views
weightbearing AP
used to assess joint line symmetry
full-length AP
used to assess overall mechanical alignment
lateral
used to assess femoral component sizing (assess posterior condylar offset compared to native), tibial
subluxation, recurvatum
flexion lateral can often see paradoxical rollback in PCL incompetent CR knees
Findings
extension instability
excessive distal femoral resection
oversized femoral component
reverse tibial slope
flexion instability
overresection of posterior femoral condyles
undersized femoral component
increased tibial slope
mid-flexion instability
anterior or proximal placement of femoral component (look at the joint line to fibular head distance for
joint line elevation)
genu recurvatum
TKA patellar maltracking
Recommended views
AP
used to assess placement of femoral component and Q angle
lateral
used to assess femoral component anterior offset (overstuffing)
tangential
used to assess subluxation of patella, placement of patellar component, angle of patellar resection, an
Findings
laterally subluxed patella
increased Q angle
anterior placement of femoral component
asymmetric patellar resection
lateral placement of patellar component
lateral osteophyte on patella
TKA patellar prosthesis loosening
Recommended views
lateral
tangential
Findings
loss of radiolucent space in patellofemoral joint with contact between patella bone and femoral compon
seen on lateral view
dissociated patellar component
patellar component adjacent/superficial to patella
seen on lateral and tangential views
thinning of polyethylene
seen on tangential view
TKA heterotopic ossification
Classification = Furia & Pelligrini
class I = island of bone localized to suprapatellar soft tissues
class II = bone organized into areas of ossification contiguous with the anterior distal femur
grade A = ≤ 5 cm
grade B = > 5 cm
Recommended views
AP
lateral
Findings
ossification along anterior distal aspect of femur and within quadriceps mechanism
typically visible 3-4 weeks post-operatively and matures within 1-2 years
Treatment criteria
nonoperative treatment acceptable in most cases
excision if
quadriceps muscle snapping
patellofemoral tracking difficulties
patellofemoral instability

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