0:00

So again, I am privileged to be able

0:04

to introduce Minnie Patria to you.

0:07

Uh, Minnie, I don't know if you were tuned in a little bit

0:10

earlier, but at least on one occasion someone complimented

0:13

your eyes about

0:15

I heard that. Thanks

0:16

Brady.

0:18

Not surprising by the way.

0:20

It doesn't surprise any of us,

0:22

but in any case, uh, Minnie is going to give back

0:25

to back talks now on two things, the extensor mechanism

0:29

and then the, uh, papa fossa.

0:32

Okay, so Minnie, it's all yours.

0:34

Great, thank you. Well, we had a series of wonderful, uh,

0:39

talks on the ligaments in the front

0:42

or in the back and the side.

0:44

Uh, now we don't have much left, so what I'm gonna focus on

0:47

for the next 45 minutes is to discuss the anatomy

0:51

and the anterior knee, uh,

0:53

focusing in on the extensor mechanism.

0:56

We all deal with anterior knee pain very commonly in our

1:00

clinical practices, and there are a number of causes,

1:02

and I'd like to just use a layered approach when I'm

1:06

evaluating patients with anterior knee pain.

1:09

And the four layers that I'd like

1:10

to look at are gonna be the superficial layer,

1:13

which is the skin and subq tissues,

1:15

the extensor mechanism itself, the fat pads along the front

1:20

of the knee, and then finally looking

1:22

for disorders within the articulation itself.

1:24

And I'm not gonna have any time to really go into the latter

1:28

in this particular presentation.

1:30

So let's start first by the pre patella soft tissues.

1:33

There were really two main issues that we have

1:36

to look at in this area, and those are bursitis

1:41

and trauma related lesions, including both hematomas

1:45

and the morel, uh, LAVALLE lesion.

1:47

There's fascia in this area,

1:49

and I will show you one example of thickening of

1:52

that subcutaneous fascia at the end

1:54

of this particular section.

1:56

Now, there are three main bur side that you want to look at,

2:00

and these bur side, two of them are

2:03

outside the patellar tendon known

2:05

as the superficial pre patellar,

2:07

and the superficial in patellar bursa in, in my opinion,

2:11

in chronic bursitis.

2:12

These will often communicate with each other, so we wind up

2:16

with a large bursa covering the entire tendon.

2:19

The other bursa is separate,

2:21

and that is the deep infra patella bursa not distended in

2:25

this example, and that bursa is going to be

2:28

inside the tendon has different etiologies

2:31

for why it might be inflamed.

2:33

Uh, so those are the areas that we wanna look at.

2:37

Now, I have never really been clear exactly

2:39

where these buri lie relative to the different layers

2:43

of soft tissue anterior to the patella.

2:46

This is taken from an, uh, an article by Scott Dye going

2:50

through the various fascial layers

2:52

and potential places for buri.

2:55

One between the skin and the superficial fascia.

2:58

Another between the superficial fascia

3:01

and crisscrossing fibers from the vasts medias and laterals.

3:06

And then finally, a third potential space anterior

3:10

to the bone and anterior to the rectus femoral fibers

3:13

that insert directly onto the patella.

3:15

But in terms of clinical practice, it's really difficult

3:19

to tell which are involved

3:20

or whether all of them are involved.

3:22

These are some images, uh, taken from, uh, Dr.

3:26

Resnick's, uh, lab, a paper on this area with injection

3:30

of dye into the pre patellar buri.

3:35

Uh, and you can see here again that it's very difficult

3:38

to sort out exactly where these structures are located.

3:41

Unfortunately, D'S paper really only looked at

3:46

the space in front of the patella

3:47

and didn't dissect above and below.

3:50

This is from that article that I alluded to that Dr.

3:53

Resnick was involved with,

3:55

and they illustrated these three potential places

3:58

between these layers of soft tissue at the anterior knee.

4:03

But again, even reading the article is really quite unclear

4:07

even in these cadavers, which of those layers is affected

4:10

and how frequently, uh, they can, uh, communicate, uh,

4:14

with each other.