share
play prev play next
play fullscreen
1 / 111
Sıra DOSYA ADI Format Bağlantı
01. Tissue Patellofemoral Sport Sport ppt Sunumu İndir

Transkript

[1]
WORKSHOP The Patellofemoral Pain Enigma The Etiology and Safe Treatment from A Tissue Homeostasis PerspectiveScott F. Dye M.D.Associate Clin. Prof.University of California San FranciscoEnvelope of Function
[2]
Anterior Knee PainNumbers are VAST! “The Most Common Condition of the Knee”Yet the Etiology and Treatment of AKP remainA Source of Debate WHY?
[3]
“Study Principles not Methods. A Mind that grasps Principles will devise its own Methods” A. Bruce Gill:
[4]
Anterior Knee Pain Has Resisted All Attempts At Explanation by the Standard Structural/Biomechanical Paradigm Whose Explanation Has Been: “AKP is Caused By Chondromalacia Patella or Malalignment/ Maltracking”
[5]
Why is Treatment of the Painful PF Joint So Difficult?The Symptoms are by definition,Based ultimately on SUBJECTIVE Report Of CNS EventsThe PF Joint Withstands the highest Loads of ANY M/S ComponentTherefore The P/F Joint Is an ExtremelyHarsh Biomechanical in which to expect Clinical Improvement and is UNFORGIVINGOf any Treatment esp. Surgery or PT which Does not Respect its unique Biologic Characteristics
[6]
The SymptomaticPatelloFemoral JointTwo Main Problems:InstabilityPain
[7]
PatelloFemoral Pain“Curiously, despite the widespreadUse of MRI and arthroscopy the genesis of patellofemoral pain still remains An Orthopaedic Enigma”John InsallReflects Inadequacy of the currentBiomechanical/Structural Paradigm1995
[8]
ORTHOPAEDIC IMAGINGStructuralX-rayCTMRIUltra-sound MetabolicTc Bone ScanPETCombinationPET-CT
[9]
The Problem:Belief in a PureBiomechanical/StructuralParadigm of Knee Function
[10]
The Entire Orthopaedic Surgical Profession Has been based on a Structural/Biomechanical Paradigm Since its InceptionOur Entire Lexicon Reflects This Bias: Fractured Bone – Stabilize It Herniated Disc - Remove Herniation Ruptured ACL – Reconstruct It Ruptured Tendon – Repair It Dislocation – Reduce It Chondromalacia – Create New Cartilage (ICRS)
[11]
•Address the observable Structural/Biomechanical factorsi.e. Chondroplasties.Lateral releasesProximal and Distal realignments•The Pre-Injury Knee FunctionHas been RestoredTherefore: Return to Sport is SafeDJD of the Knee will be PreventedASSUMPTION:
[12]
The Worst CasesIatrogenic!7 Operations 9 Operations5 OperationsOf PF PAIN
[13]
How Best to Achieve Restoration of Joint Function?By RestorationOf NormalStructural/BiomechanicalCharacteristics?(Conceptually Limited-Ignores Important oftenOccult,Biological Factors)By Restoration ofTissue Homeostasis(An Emerging Orthopedic Paradigm) Discovered In Response to The Enigma of PFPS
[14]
What is The Pathophysiology?Of Patellofemoral Pain
[15]
PatelloFemoral PainStructural/Biomechanical Paradigm Chondromalacia MalalignmentMetabolic/Physiologic Paradigm Tissue HomeostasisThe Etiology of
[16]
Chondromalacia PatellaMAYO Clinic: “Damage to the cartilage under your kneecap. A more accurate term for chondromalaciapatella is Patellofemoral Pain Syndrome” !Internet search July 29th 2014
[17]
Chondromalacia PatellaWikipedia: “Inflammation of the underside of the patella, softening the cartilage. More accurately referred to as patellofemoral pain syndrome. The cartilage is no longer smooth and therefore use and movement is painful” !Internet search July 29th 2014
[18]
ChondromalaciaArticular CartilageHas no Neural FibersNormal Bone ScanNo Sensation To Probing Of my own Patellar Articular Cartilage!
[19]
Palpation of my right Patella = NO PAIN ! Advanced Structural Damage of ArticularCartilage (CMP)OsseousHomeostasis
[20]
T1 rho Sagittal MRI Same Knee 13 years LaterBLUE=Normal PG Content RED= Diminished PG Content (Courtesy of Ben Ma UCSF)
[21]
MY Concurrent Tc99m-MDP Bone Scan
[22]
2013+T1 rhoGrade 3 CMP AsymptomaticX 13 Years, in Face ofNormal Tc Bone ScanTissue Homeostasis of Bone TRUMPS StructuralDamage of Articular Cartilage DYE
[23]
My Current Bone Scan (May 2014)Maintenance/ Persistance Of Joint Homeostasis X 14 Years200920112014
[24]
CMP Does NOT Cause PF PAIN!
[25]
Malalignment
[26]
BiedertRM,et al. Correlation between The Q angle and Patellar Position Arch Orthop Trauma Surg 121 2001DyeSF, BollDH, DuniganPE: An AnalysisOf objective measurements in young patientswith patellofemoral pain Am J Sports Med 13 1985PostW: Current assessment of the value of clincal indicators of Malalignment. Spots Med Arth Rev 2001SandowMJ, GoodfellowJW: The natural history of anterior knee pain in adolescents JBJS 67B 1985ThomeeR,et al. Patellofemoral pain syndrome in young women : A clinical analysis of alignment,pain parametersScand J Med Sci Sports 5 1995Patellofemoral Pain does NOT Correlate with Malalignment
[27]
104 patients with AKP 79 ControlsNo Statistical difference: Q Angle Insall-Salvati Index Merchant View Congruence Angle Sulcus Angle Laurin View Lat P/F Angle P/F Index Lat Patellar DisplacementMeniscus of Sclerosis—Lat pat FacetPerpendicularization of Trabeculae—Lat Pat FacetDye, Boll, Dunigan,et al. Am JSM 1985LETTERMAN ARMY MEDICAL CENTER Presidio of San Francisco
[28]
H.U. Staeubli et al. JBJS Br 1999Articular Cartilage MorphologyDoes not often match Osseous Morphology
[29]
Osseous LandmarksIndicate MalalignmentHowever The Cartilage Surfaces Mate PerfectlyPlain CT CT ArthrogramStaeubli et al., JBJS Br 1999
[30]
[31]
J.Y. DuPont
[32]
Pain arises fromInnervated StructuresTENDONSYNOVIUMBONEVESSELSRETINACULAR NEUROMA
[33]
Biedert, RM,et al., The Occurance Of free nerve endings in the soft tissuesOf the knee joint.Am J Sports Med 1992Sanchis-Alfonso,V,et al.,Quantitative analysisOf nerve changes in the lateral retinaculum,Am J Sports Med 1998Sanchis-Alfonso,Vand Rosello-Sastre,EImmunohistochemical analysis for neuralMarkers of the lateral retinaculum Am J SportsMed, 2000Biedert,RM, and Kernen,V, Nerosensory Characteristics of the Patellofemoral JointSports Med Arthrosc Rev 2001
[34]
A Variable MOSAIC Of PathophysiologyLoss of Tissue Homeostasis Of Innervated Patello-Femoral Structures Best Accounts for theVariable expression ofPatelloFemoral Pain
[35]
Loss of osseous Homeostasis P/F SynovitisTwo Main“TILES “Of theMosaicNormal SynoviumNormal Patellar Bone
[36]
[37]
Positive Patellar Bone Scan 28 yo Female with P/F PainNormal Radiographs 1982
[38]
[39]
[40]
Osseous HomeostasisLoss of Osseous HomeostasisTissue Homeostasis
[41]
28 yo Male with AKP No MalalignmentPositive Bone ScanPre Rx Resolution of AKPNegative Bone Scan4 Months ConservativeRx
[42]
Stanford Radiology Confirmed our Findings With High Resolution PET-CT Tc99m-MDP Bone Scan = 4 ms PET-CT = 25 msBut It Is Very High Radiation
[43]
[44]
[45]
Homeostasis Loss of HomeostasisRestoration ofHomeostasisPre Needle Penetration 7 weeks Post 14 Months Post
[46]
Dye and Chew JBJS (Am) 1993
[47]
Dye’s Model of Bone Homeostasis
[48]
Principle of TreatmentRestoration of MusculoskeletalFUNCTION
[49]
What is the FunctionOf the Knee ?
[50]
The Knee Functions as a Biologic TransmissionCORR 1996MENSCHICK
[51]
The Knee is a Biologic TransmissionOne Trillion living, metabolically active cellsSelf-maintaing, Self-repairing System 2 to 8 Million Load cycles/ Year for DecadesLigaments are Sensate , Adaptive LinkagesMenisci are Mobile, Sensate Bearings CORR 1996
[52]
Muscles are Molecular Engines
[53]
PURPOSE:To Accept, Transfer andDissipate Loads Between Femur, Patella, Tibia ,Fibula
[54]
Ligaments =Sensate LinkagesMenisci = SensateMobile BearingsMuscles =Cellular Engines
[55]
The PatelloFemoral JointA Large Slide BearingFunctions asWithin the Biologic Transmission
[56]
The PatelloFemoral JointIs Exposed to the HighestLoads of All Human JointsOften Exceeding the Load AcceptanceCapacity of Biologic Structures,Leading to Micro failure and PainfulLoss of Tissue Homeostasis
[57]
Defines the Capacity of the Knee(any Joint or M/S) To accept a Range of Loads and still Maintain Tissue HomeostasisThe Envelope of Function
[58]
[59]
[60]
Disuse Atrophy
[61]
[62]
[63]
[64]
FACTORS Determining the EnvelopeAnatomic/StructuralKinematic/NeuromuscularMetabolic/PhysiologicTreatmentPET Scan Fl 18CORR 1996
[65]
Goal of Treatment:Maximize the Envelope of FunctionAs Safely and PredictablyAs PossiblePRIMUM NON NOCERE!
[66]
I Decrease Loading to within the current Envelope of FunctionII An Anti-inflammatory programIII Rehabilitation
[67]
[68]
[69]
[70]
[71]
[72]
[73]
Healing is a Rate-LimitedProcess!Patience is a Virtue
[74]
An Anti-inflammatory ProgramNSAIDs Physicians’ Choice(Kenalog Injection)Tissue cooling, IcingIcingX 20 MinAnkle Bone Scan Pre- icingAnkle Bone Scan Post- icing
[75]
RehabilitationPainless Muscle Strengthening, Stretching,Increase in ROM, Proprioception Within the Envelope of Function!
[76]
No PainNo Gain! ?
[77]
NO!Any activity that increases P/F Pain Must be AvoidedPain = Loading out of the Envelope!Lunges
[78]
McConnell TapingStretchingYES !
[79]
[80]
The PatellofemoralJoint isUNFORGIVING!Of Aggressive or Ill considered Surgical Intervention
[81]
The Knee is aHigh Value Asset!We Should NOT Risk Its Destruction
[82]
The Worst Cases Are Iatrogenic!7 Operations 9 Operations5 OperationsOf Patellofemoral Pain
[83]
Lateral RetinacularRelease
[84]
Fulkerson Osteotomy
[85]
[86]
ChondroplastiesAutologous Chondrocyte Transplantation
[87]
Patellofemoral Replacement
[88]
[89]
[90]
Patellar InstabilityVery Often Due To Reflex InhibitionOf the Quadriceps 2nd ToSynovial Impingement(Mis-Interpreted as Mal-tracking)
[91]
Ouch!Rationale for PeriPatellar Synovectomy
[92]
SynovitisSynovial Impingment
[93]
Patellofemoral Synovectomy
[94]
Typical SynovectomyPlenty of Nerves HereMeticulousHaemostasisGentle, Low-Energy,Conservative.Pre and Post-OperativeManagement Critical
[95]
Patellofemoral Synovectomy
[96]
Normal Synovium Synovitis
[97]
Pathology : Synovial Hyperplasia Lymphocyte Aggregations Chronic non-specific Proliferative SynovitisNormal Synovium
[98]
Synovectomy Meticulous Intra Op Hemostasis! 40cc 1% Lido with Epi 50cc ¼% Marcaine All Knees Drained Min 3hrs GENTLE P/O RehabMUST AVOID a HEMARTHROSIS!(Sub-Synovial)(Intra-articular)
[99]
[100]
[101]
66 yo Male Left Anterior Knee Pain
[102]
Synovectomy, Gentle ChondroplastyCareful Post Op Rehab, In the Envelope!Daily icing, NSAIDS,Persistent Exercise Program, In the Envelope!
[103]
4yrs 8ms Post Op PAIN FREENo Change of X-raysImprovedBone ScansTowards Homeostasis
[104]
4yrs 8ms Post Op PAIN FREENo Change of X-raysImprovedBone ScansTowards Homeostasis
[105]
Pre op 4yrs 8ms Post OpPatellar Activity Much ImprovedCan Be “Disease Modifying”
[106]
3 Conditions to R/OHip PathologySaphenous Nerve ImpingementSomatization (Esp in Teen Females) 2nd to Abuse (Sexual, Physical)
[107]
“A Most Amazing Case”
[108]
Something As Simple As a ¼ Inch Lateral Sole Wedge CAN Actually BE DISEASE MODIFYING!Represents HOPE for Millions of Pts Who Can’t AffordOr Do Not Wish to Proceed with Major Surgery! Obvious Implications for Our Patients as Well as The WORLD HEALTH ORGANIZATION
[109]
Benefits of a PeriPatellarSynovectomy / Gentle ChondroplastyAims Directly at Common Source of Patellofemoral PainRelatively Gentle and RecoverableDoesn’t “Burn any Surgical Bridges”
[110]
2006
[111]