0:00

The history on this one was a 20 year old with right knee pain with, uh,

0:06

anterior or with motion perhaps. Okay.

0:09

So here we were provided with, uh, localizers. So here,

0:13

obviously I'd be looking at the localizers, and right off the bat,

0:16

I'm wondering, I don't know, something going on at the condyle.

0:19

So I'm wondering if there's an ACL reconstruction.

0:22

So what I would tell my, uh, uh,

0:25

support staff or my fellows to look for that history. Okay? So going through,

0:31

uh, this, okay,

0:33

so we see here that this actually is a screw, okay?

0:38

Within, uh, at about the region of the, uh,

0:41

distal femoral metaphysis right here. And we'll look,

0:44

we'll get a better look at that on your coronals and sagittals. Okay?

0:48

But going to the, to the finding the saline findings on this, uh,

0:53

imaging we see bright okay? Signal, okay.

0:57

Within fluid bright signal within intrasubstance, within the patellar tendon.

1:02

So obviously we're gonna call this tendinosis and tear, okay?

1:06

Accompanied with, uh, high grade, uh,

1:09

chondral abnormalities within the trochlea with some sub chondral cystic change

1:13

in early osteoarthritic bone marrow changes. Okay? Now, uh,

1:18

what I kind of mentioned earlier,

1:20

and this kind of dovetails to quite case number one, okay?

1:24

You notice here that the, uh,

1:26

quadriceps patella tendon continuation of that pre patellar P plate is, uh,

1:31

uh, better in appearance or more normal in appearance as opposed to case one.

1:36

Okay? We also have some tendinosis at the proximal patellar tendon, okay?

1:41

And then we have some edema,

1:43

non-specific sort of within the deep aspect of HVAs fat pad, okay?

1:47

But anytime, uh, I'll call a tendon chair, right?

1:51

Other things I wanna make sure is it's not complete, okay? If it's complete,

1:56

wanna make sure to,

1:57

to mention how far it's retracted and if there's patella alta,

2:02

some people, and along the lines of patella alta as a quick tangent, okay?

2:06

There's a whole bunch of measurements that you can use. Okay? Uh,

2:10

just rattling a few off the top of my head. There's what these,

2:13

there's the inal body, there's the modified inal body, there's the,

2:18

uh, the, the Blackburn peel, the, uh,

2:22

Duchamp Canton, and, and I think maybe one or two others. But, um,

2:27

you know, you can follow up the literature on that and, and figure out, uh,

2:32

what's the most specific incentive for, but for me, I like a,

2:36

just a nice good old radiograph or, or a sagittal, uh, MRI.

2:40

And what I look for is, uh, look for, uh,

2:43

good or de at least AS at least a small amount of cartilage overlap between the

2:49

inferior aspect of the patella and trochlea.

2:52

If I see that that is off, okay, then I'll start. Look, then I'll start using,

2:57

you know, the miss me or, or the ISI or, or what, what, whatever, um,

3:02

uh, parameters that you decide to use.

3:04

And I will provide that for the clinician.

3:07

Or if the clinician prefers a certain measurement,

3:10

then I'll go ahead and read that as so for the clinician, um,

3:14

patella tendon tears not uncommon. Uh, here, uh, also,

3:19

uh, we see these more commonly with, uh, uh, jumpers. Okay? Um,

3:25

and also people with, in older populations with chronic diseases, again,

3:29

those with, uh, renal failure or systemic problems,

3:32

say with rheumatoid arthritis, perhaps even sometimes crystal's disease.

3:37

And the time you want to think about crystal's disease, particularly right?

3:41

If you have gout, okay? Gout. When in gout, think of gout.

3:45

Anytime you have an erosion of the patella,

3:47

I want you to keep that in your bag of differential diagnoses. For some reason,

3:52

gout has a predilection for the patella, particularly that patella base.

3:57

Other things to tip you off for potential, um, uh,

4:00

systemic processes like rheumatoid arthritis and gout could include synovitis,

4:05

okay? In the remainder of the joint.

4:07

And also erosions other spots that gout does to involve, okay?

4:12

Is the popal sulcus, okay? And the peri cruciate, uh, area. Okay?

4:16

And sometimes you will get choric calcinosis, but as we know,

4:21

or some of you all know, conjun calcinosis is just an imaging finding, okay?

4:25

And, um, you know, it can't happen with gout, also with CPPD amongst others,

4:30

right? So you wanna, if you're, but if you're thinking of crystals,

4:33

obviously you want to tap it, um, uh,

4:36

and analyze for that negatively bio infringement, crystals, uh,

4:40

namely with gout, because uric acid levels can be, uh,

4:45

negative and non-helpful, um,

4:48

particularly in acute attacks in patients.

4:51

So something to think about.

4:53

But this is just a nice run of the mill case of a patellar tendon tear,

4:57

as we can see here also. And these coronal images.

5:01

And here on this, uh, um,

5:04

T two or PT pd, uh, sequence with this, uh,

5:09

tend tendon tear in intrasubstance centrally. All right.

5:14

And just to round out too, okay, this person obviously had, uh,

5:20

probably either prior or remote injury okay. Of the tibial tubercle,

5:23

whether it's a avulsion fracture or probably osco schlager's disease.

5:28

Okay? And then also as, just to point out this,

5:31

this patient probably had prior repair of their, uh,

5:35

medial supporting structure. Specifically in this case,

5:39

I would argue the medial Patel femoral ret aum with this, uh,

5:43

bone anchor or suture anchor right here at, uh, in the region of the, uh,

5:48

adductor tubercle. Okay?

5:51

Could you take us through the poster lateral corner on this study,

5:54

or I found it a little bit busy and a little bit hard to

5:56

Pick apart. Yeah, yeah, sure, sure. So, poster lateral corner,

6:00

and depending on who you read, Lara, um, you know,

6:04

various other authors, the poster lateral corner, I'm still confused by it. Uh,

6:09

and it's, it's, I modify what I include and not include in that,

6:14

uh, uh, area of the knee.

6:18

But most people will, uh, include, um, uh,

6:22

from what I remember, the FCL, which is this structure right here, okay?

6:27

The pop lids right here to its insertion. Remember,

6:31

that's one of the reverse muscles of the body. That is,

6:34

it goes from distal to proximal. Okay?

6:37

And then off of that you have the, uh, popio fibular ligament.

6:42

Some people make a big deal about the reverse yha or that y shaped ligament,

6:46

the arcu ligament. But in all honestly, I typically don't see it. Uh,

6:51

maybe it, it's seeing me,

6:53

but when I see edema here at the posterior lateral coronary of the knee,

6:57

particularly with the ACL injuries,

7:00

that's when I start paying attention to that region. Okay?

7:03

Other things I look for are the biceps femorals, okay? And then there's, uh,

7:08

from what I remember, three arms,

7:10

there's a short and a long direct and indirect,

7:14

and there's also a fourth arm, if I remember correctly,

7:17

that inserts right behind the SAG attachment over here, okay?

7:22

And I include that all in my checklist for this postal later corner.

7:25

So I look at the LCL, okay, the pop,

7:30

Lydia, sorry, this mouse is going faster. All right?

7:34

And then the biceps femes. Okay?

7:38

And then also the arcuate ligament. Somewhere, somewhere in here.

7:42

And then sometimes too, you have the faa. So, which,

7:45

in which case you'll have a fabelo fibular ligament all along with

7:50

the popal fibrillary ligament. Okay? And sometimes that is, uh,

7:54

is better shown on your coronal images. So another sort of look at it here, i,

7:59

I argued, this is probably the LCL,

8:01

here's probably parts of the mid third lateral capsular ligament and,

8:06

uh, confluence or,

8:08

or attachments or slips of the biceps femoris coming sort of anteriorly,

8:12

that indirect arm. Okay? And then more,

8:16

or in this region too, okay? You have the biceps femoris,

8:20

one of its main insertions right here.

8:22

And then underneath all that you have the Paus. Okay?

8:27

And then slightly more posteriorly. Okay?

8:31

See if I can sort of get it. Maybe this region right here,

8:34

the pop lidio fi ligament, something like that. Okay?