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Periprosthetic joint infection (tuhod)

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Updated Sep 2026
Illustration: knee

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ang iyong nararamdaman

Ang periprosthetic joint infection ay isang impeksyon sa paligid ng knee replacement. Maaari itong magsimula anumang oras pagkatapos ng iyong operasyon, kung minsan ay pagkalipas ng ilang buwan o kahit ilang taon. Ang tuhod ay karaniwang masakit, namamagà, at mainit. Ang sakit ay madalas na hindi humuhupa gaya ng normal na recovery, at maaaring lumala sa gabi o pagkatapos mong tumayo at maglakad.

Ang mga pang-araw-araw na gawain ay maaaring maging mahirap. Ang paglalakad papunta sa letterbox, pagtayo mula sa mababang upuan, o pagbaba ng hagdan ay maaaring mas masakit kaysa dati. Napapansin ng ilang tao na sensitibo ang bahagi ng sugat, o may likidong lumalabas mula rito. Ang isang maliit na channel sa balat na naglalabas ng likido, na tinatawag na sinus tract, ay isang malakas na senyales ng impeksyon at hindi dapat kailanman balewalain.

Ang mga sintomas ay maaaring hindi malinaw. Kung minsan, ang pangunahing problema ay hindi halatang sakit kundi isang tuhod na hindi pakiramdam na tama, na may paninigas o discomfort na dahan-dahang nabubuo. Ang impeksyon ay maaari ring magdulot ng pagluwag ng replacement, na nagiging sanhi ng sakit kapag may dinadalang bigat (weight bearing). Dahil ang mga senyales na ito ay katulad ng sa iba pang problema sa tuhod, ang impeksyon ay hindi laging madaling matukoy.

Walang iisang test na nagbibigay ng siguradong sagot. Pagsasamahin ng iyong surgeon ang ilang impormasyon: blood tests, likidong kinuha mula sa tuhod gamit ang karayom, mga scan, at ang kanilang matutuklasan kapag sinuri ka nila. Ang ilan sa mga test na ito ay maaaring maapektuhan ng mga kamakailang antibiotics, kaya mahalagang sabihin sa iyong surgeon kung may nainom ka nito. Kung pinaghihinalaan ang isang late infection, ang mga antibiotics ay karaniwang ipinagpapaliban muna hanggang sa makumpirma o ma-rule out ang diagnosis, dahil ang pag-uumpisa muna ng mga ito ay maaaring magtago sa bacteria at makasira sa mga sample.

Kung ikaw ay sumailalim sa knee replacement at ang iyong tuhod ay masakit, namamagà, o may lumalabas na likido, makipag-ugnayan sa iyong surgical team. Ang maagang assessment ay nagbibigay sa iyo ng pinakamagandang pagkakataon para sa isang straightforward na resulta.

Ano ang aktwal na nangyayari

Ang knee replacement ay isang artipisyal na surface na ikinakabit sa mga dulo ng iyong buto sa hita (thigh bone) at binti (shin bone). Karaniwan, tinatanggap ito ng iyong katawan, at ang bagong joint ay gumagalaw nang maayos. Sa isang periprosthetic joint infection, ang mga bacteria ay nanirahan sa ibabaw o paligid ng mga artipisyal na bahagi at bumuo ng isang layer na tinatawag na biofilm. Isipin ito bilang isang madulas na shield na binuo ng mga bacteria sa paligid ng kanilang sarili. Kapag nakapwesto na ang shield na iyon, nahihirapan ang iyong immune system at ang mga antibiotic na maabot sila, kung kaya't ang impeksyon ay maaaring manatili nang ilang buwan at kung bakit ang paggamot ay karaniwang kinapapalooban ng operasyon pati na rin ng mga antibiotic.

Iniririta ng impeksyon ang tissue sa paligid ng tuhod, kung kaya't ito ay nagiging masakit, namamaga, at mainit. Maaari rin nitong paluwagin ang bond sa pagitan ng mga artipisyal na bahagi at ng iyong buto, kaya ang replacement ay hindi na nakaupo nang matatag. Ang pagluwag na iyon ang nagiging sanhi ng sakit ng tuhod kapag nilalagyan mo ito ng bigat, at ito ang nagpapaliwanag sa fluid o tumatagas na sugat na napapansin ng ilang tao.

Nangyayari ito sa humigit-kumulang 1% hanggang 2% ng mga knee replacement. May ilang mga sitwasyon na nagpapataas ng panganib. Kung nagkaroon ka ng septic arthritis, isang impeksyon sa loob ng joint, noon, mas malaki ang posibilidad na magkaroon ng problemang ito pagkatapos ng knee replacement kaysa pagkatapos ng hip replacement. Ang mga problema sa sugat sa mga unang linggo pagkatapos ng operasyon ay nagpapataas din ng pagkakataon na ang impeksyon ay makarating nang malalim sa paligid ng bagong joint.

Mayroong dalawang malawak na pattern. Ang early infection ay lumilitaw agad pagkatapos ng operasyon, habang ang mga bacteria ay lumulutang pa nang malaya at hindi pa nakabubuo ng kanilang shield. Ang late o chronic infection ay nabubuo pagkalipas ng mga buwan o taon, kapag ang mga bacteria ay protektado na nang husto at nakakabit nang matatag. Mahalaga ang pagkakaibang ito, dahil ang mga early infection ay kung minsan ay maaaring gamutin sa pamamagitan ng paghuhugas (washing out) ng joint at pagpapanatili ng orihinal na replacement sa pwesto nito. Ang mga late infection ay karaniwang nangangailangan na tanggalin ang replacement at magkabit ng bago sa magkakahiwalay na yugto (separate stages).

Ano ang maaari naming gawin tungkol dito

Ang impeksyon sa paligid ng knee replacement ay hindi isang problema na maaari mong pamahalaan nang mag-isa, at ang physiotherapy o mga gamot sa sakit ay hindi ito makakapagtanggal. Ang nakakatulong ay ang maagang pagkilos. Kung ang iyong tuhod ay naging masakit, namamagâ, mainit o nagsimulang maglabas ng likido pagkatapos ng knee replacement, makipag-ugnayan agad sa iyong surgical team sa halip na maghintay kung ito ay huhupa.

Ang paggamot ay depende sa kung gaano kabilis lumitaw ang impeksyon pagkatapos ng iyong operasyon. Kapag ang impeksyon ay nangyari sa loob ng mga unang linggo, maaari naming hugasan ang joint at linisin ang mga artificial parts habang hinahayaan ang iyong orihinal na replacement sa pwesto. Ginagawa ito sa isang operasyon, at binibigyan ng mga antibiotic pagkatapos. Mas epektibo ito kapag mas maagang ginawa. Ang impeksyon sa loob ng 1 buwan pagkatapos ng operasyon ang may pinakamataas na pagkakataon na matanggal sa paraang ito, at bumababa ang pagkakataon habang lumilipas ang panahon. Para sa mga impeksyon sa loob ng 12 linggo pagkatapos ng operasyon, ang approach na ito ay isang kinikilalang opsyon.

Ang impeksyong lumilitaw nang mas huli ay karaniwang nangangailangan ng mas malaking operasyon. Tinatanggal ang infected replacement, naglalagay ng antibiotic spacer sa tuhod, at binibigyan ng mga antibiotic sa loob ng isang panahon. Ang spacer ay isang pansamantalang block na nagpapanatiling bukas sa espasyo at nagbibigay ng gamot na antibiotic nang lokal. Kapag kontrolado na ang impeksyon, isang bagong replacement ang ikakabit sa ikalawang operasyon. Ang two-stage approach na ito ang karaniwang paraan upang gamutin ang isang established infection, at nakakamit ang isang tuhod na walang impeksyon sa halos dalawang ikatlo ng mga kaso. Ang ilang mga tao na may partikular na mga problema sa kalusugan ay nahaharap sa mas mahirap na proseso, at tinitimbang namin ito kasama mo kapag pinaplano ang paggamot.

Ang pagpili ng paggamot ay isang shared decision. Tinitingnan namin kung gaano katagal na ang nakalipas mula nang gawin ang iyong replacement, kung anong mga bacteria ang sangkot, ang iyong pangkalahatang kalusugan at kung gaano kalala ang kondisyon ng tuhod. Pagkatapos ay ipapaliwanag namin kung aling opsyon ang angkop para sa iyo at kung ano ang mga kasama nito, at magdedesisyon ka kasama namin kung paano magpapatuloy.

Ano ang dapat asahan

Ang outlook ay nakadepende nang malaki sa kung gaano kaaga natuklasan at nagamot ang impeksyon. Kapag ito ay nahuli agad pagkatapos ng iyong operasyon, ang paghuhugas ng joint at pagpapanatili ng iyong orihinal na replacement ay maaaring maging epektibo. Kapag ito ay nagamot sa ganitong paraan nang maaga, ang tuhod ay nananatiling walang impeksyon pagkalipas ng 1 taon sa 76% ng mga kaso. Habang mas maagang ginagawa ito, mas malaki ang pagkakataon na ito ay gumana, at ang pagkakataong ito ay bumababa habang lumilipas ang panahon.

Ang impeksyong lumilitaw nang mas huli ay karaniwang nangangailangan ng two-stage approach na inilarawan kanina. Ang isang tuhod na walang impeksyon ay nakakamit sa halos dalawang katlo ng mga kaso gamit ang gamutang ito. Ang ilang bacteria ay mas mahirap puksain kaysa sa iba, at ang mga impeksyong kinasasangkutan ng higit sa isang uri ng bacteria ay may tendensiyang magkaroon ng mas mahirap na kurso. Ang mga taong may iba pang kondisyong pangkalusugan ay maaari ring humarap sa mas mahirap na proseso. Kung ang impeksyon ay bumalik pagkatapos ng gamutan, karaniwang kinakailangan ang karagdagang operasyon.

Ang pagpapabaya sa impeksyon ay hindi gumagana. Pinoprotektahan ng mga bacteria ang kanilang sarili sa paraang hindi maabot ng iyong katawan at ng mga antibiotic, kaya ang sakit, pamamaga, at pagluwag ay may tendensiyang magpatuloy o dahan-dahang lumala. Habang tumatagal ito, mas nagiging mahirap itong gamutin.

Ang paggaling pagkatapos ng gamutan ay nangangailangan ng panahon. Maraming tao ang nakakaramdam na gumagalaw nang maayos ang kanilang tuhod kapag nawala na ang impeksyon, at ang mga taong matagumpay na nagamot ay madalas na nag-uulat na mas mabuti ang pakiramdam ng kanilang tuhod kaysa noong bago magsimula ang impeksyon. Ngunit ang landas ay hindi laging madali. Ang ilang tao ay nangangailangan ng higit sa isang operasyon, at ang maliit na bilang ay nangangailangan ng mas malaking salvage surgery kung ang impeksyon ay hindi mapuksa sa anumang ibang paraan.

Ang iyong surgical team ay magbabantay nang maigi sa iyo sa unang 2 taon pagkatapos ng gamutan, dahil ito ang panahon kung kailan pinaka-malamang na bumalik ang impeksyon. Kung ang iyong tuhod ay muling maging masakit, mamaga, o uminit sa anumang oras, makipag-ugnayan agad sa iyong team sa halip na maghintay kung ito ay huhupa.

Kailan dapat magpatingin

Ang impeksyon sa paligid ng knee replacement ay kailangang masuri agad. Makipag-ugnayan agad sa iyong surgical team kung ang iyong tuhod ay naging masakit, namamagà, o mainit, o kung may likidong nagsisimulang lumabas mula sa sugat. Pumunta sa emergency department kung ikaw ay may lagnat, pangkalahatang masama ang pakiramdam, o kung ang pamumula at pamamaga ay kumakalat lampas sa tuhod. Humingi ng specialist review kung ang iyong tuhod ay hindi naging maayos mula pa noong operasyon, na may kasamang sakit na hindi nawawala, paninigas na patuloy na lumalala, o discomfort na mas matindi sa gabi. Ang isang maliit na channel sa balat na naglalabas ng likido ay kailangang masuri nang walang pagkaantala. Kung ang iyong tuhod ay nagamot na para sa impeksyon noon at bumalik ang parehong mga sintomas, makipag-ugnayan muli sa iyong team sa halip na maghintay kung ito ay mawawala.

Reviewed by AI synthesis (v2) — pending human review · 9 September 2026.

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Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Bony Anatomy

  • The bones of the knee are the distal femur, the proximal tibia, and the patella [1].
  • The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [4].
  • The lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial femoral condyle [4].
  • The tibial articular surface slopes 7° to 10° in the sagittal plane [4].
  • The medial tibial plateau is larger than the lateral plateau and is concave in its frontal and sagittal planes [4].
  • The lateral tibial plateau is smaller and more circular than the medial plateau, concave in the frontal plane and convex in the sagittal plane [4].
  • The patella is the largest sesamoid bone in the body, averaging 2.5 cm in thickness [4].
  • The patellar articular surface contains a vertical, central ridge that separates the broader lateral facet from the medial facet, and a smaller, more medial facet called the odd facet [4].
  • The posterior slope of the tibia is a mean of 10.7° in the medial plateau and 7.2° in the lateral plateau [9].
  • The fibular head is located a mean of 1.5 cm distal to the joint line, with a range of 6 to 32 mm [9].

Ligaments

  • The anterior cruciate ligament (ACL) prevents anterior translation and rotation of the tibia on the femur [1].
  • The posterior cruciate ligament (PCL) prevents posterior subluxation of the tibia on the femur [1].
  • The medial collateral ligament stabilizes the knee to valgus stresses [1].
  • The lateral collateral ligament is the main stabilizer against varus stress [1].
  • The ACL is composed of 90% type I collagen and 10% type III collagen [4].
  • The mean length of the ACL is 33 mm and the mean midsubstance width is 11 mm [4].
  • The femoral attachment of the ACL is a semicircular area on the posteromedial aspect of the lateral femoral condyle [4].
  • The tibial attachment of the ACL is a broad, irregular, oval-shaped area slightly medial and anterior to the midline between the tibial spinous processes [4].
  • The PCL is the largest of the intra-articular ligaments, with an average length of 38 mm and a mean diameter at the midpoint of 13 mm [17].
  • The PCL has two distinct bundles: an anterolateral (AL) bundle comprising 85% of the cross-sectional area and a posteromedial (PM) bundle [17].
  • The PCL inserts onto a midline depression on the tibia, 10 to 15 mm below the level of the tibial plateaus [17].
  • The meniscofemoral ligaments connect the posterior horn of the lateral meniscus to the intercondylar notch and are thought to be secondary restraints to posterior translation [17].
  • The anteromedial bundle of the ACL is tight in knee flexion and the posterolateral bundle is tight in knee extension [9].
  • The posterolateral bundle of the ACL is responsible for preventing the pivot-shift phenomenon [9].
  • The anterolateral bundle of the PCL is stronger and stiffer than the posteromedial bundle and is tight in knee flexion [9].

Menisci

  • The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase joint congruency, enhance stability, and aid in synovial fluid distribution [1].
  • The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [1].
  • The lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [1].
  • The medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [1].
  • The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [1].
  • The menisci consist of type I collagen fibers arranged obliquely, radially, and vertically [9].
  • Vascular supply to the menisci is derived from the geniculate arteries, which penetrate into 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [9].

Vascular and Nerve Anatomy

  • The blood supply to the knee is formed from an anastomosis around the knee derived from the descending geniculate artery, superior and inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [4].
  • The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [4].
  • The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [4].
  • The posterior articular branch of the tibial nerve is the largest nerve providing innervation of the intra-articular knee [4].
  • The popliteus artery travels through the adductor hiatus, where it is relatively immobile, and distally through the fibrous arch deep to the soleus muscle [14].
  • The common peroneal nerve travels along the posterior edge of the biceps femoris and continues distally around the fibular neck [14].

Kinematics

  • The knee is a hinge joint that incorporates both gliding and rolling, which are essential to its kinematics [5].
  • The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [5].
  • The greatest range of motion occurs in the sagittal plane, approximately 160° [21].
  • Knee rotation ranges from 45° in external rotation to 30° in internal rotation [21].
  • In the frontal plane, the range of motion in both abduction and adduction reaches a maximum of 10° [21].
  • During walking, knee range of motion reaches approximately 70° in the sagittal plane, 15° in the frontal plane, and 10° in the transverse plane [21].
  • The normal instant center of the knee joint follows a semicircular path related to the tibiofemoral surface and ligaments crossing the joint [21].
  • Rupture of the cruciate ligaments or disruption of the tibiofemoral surface causes a major change in the path of the instant center, leading to articular dysfunction [21].
  • In full extension, the knee slightly hyperextends with slight tibial external rotation while collateral and cruciate ligaments are tightened to lock the knee [22].
  • The popliteus muscle initiates flexion by pulling the lateral femoral condyle backward while the medial femoral condyle slides forward, resulting in tibial internal rotation [22].

Synovial Anatomy

  • Embryologically, the knee joint forms from three synovial compartments that normally fuse into a single synovial cavity [16].
  • The important synovial plicae of the knee represent unresolved remnants of these partitions and are classified as suprapatellar, infrapatellar, medial patellar, and lateral patellar plicae [16].
  • The medial patellar plica is the most common plica to be of clinical significance, with an incidence reported to range from 10% to more than 50% in normal knees [16].
  • A pathologic medial patellar plica makes firm contact with the underlying femoral condyle at 30 to 40 degrees of flexion [16].
  • In some patients, a median septum separates the posterior aspect of the knee into two compartments, with the posterior cruciate ligament projecting anteriorly in the septum [19].

Investigations

Plain Radiography

  • Plain radiographs are appropriate initial imaging studies for most knee conditions, allowing assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [3].
  • Standard knee imaging includes anterior-posterior (AP), lateral, and axial views (skyline, sunrise, sunset) [27].
  • Supine AP knee radiographs do not adequately estimate joint space width needed to estimate the degree of osteoarthritis progression [27].
  • A 45° standing flexion view was introduced to better evaluate joint space because plain frontal radiographs may not accurately display actual joint space due to cartilage wear patterns, meniscal integrity, or tibial slope variances [27].
  • The fixed flexion view (FFV) is a technique with improved reproducibility for evaluating joint space, involving a 10° caudal irradiation angle and specific limb positioning [27].
  • The Lyon Schuss view (LSV) uses fluoroscopic adjustment of the irradiation angle relative to the medial tibial plateau, which is more accurate for measuring actual joint space width but involves higher radiation exposure and more complex positioning [27].
  • Goniometer readings of long limb alignment or measured on a fixed flexion view correlate well with angles measured on long limb radiographs, providing an alternative if long limb radiographs are not available [27].
  • Radiographs are the standard for initial evaluation of knee pain, including weight-bearing AP and lateral views, a 45-degree flexion PA view, sunrise view, extension and flexion lateral views, and standing full-length AP radiograph [23].
  • The Kellgren-Lawrence (KL) classification grades osteoarthritis severity from 0 to 4 based on AP knee radiographs, using features such as osteophytes, joint space narrowing, subchondral sclerosis, and bone shape alterations [23].
  • Knee arthroplasty is recommended when KL Grade 4 findings are present [23].
  • Radiographic studies help confirm the clinical diagnosis of a joint disorder determined using history and physical examination [3].

Computed Tomography (CT)

  • CT provides enhanced bone detail through three-dimensional imaging with ionizing radiation [3].
  • CT imaging in axial, sagittal, and coronal planes helps visualize fracture lines, displacement, osteolytic lesions around joint arthroplasty, and cortical disruption in cases of infection or neoplasia [3].
  • Three-dimensional CT reconstructions assist in preoperative planning for complex intra-articular fractures, multiplanar osteotomy for limb malalignment, and reconstitution of bone loss in joint arthroplasty [3].
  • Axial plane CT imaging of the knee helps assess the rotational alignment of components in total knee arthroplasty in cases of patellar maltracking [3].
  • Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [23].

Magnetic Resonance Imaging (MRI)

  • MRI is the most useful study for differentiating osteonecrosis from other conditions such as osteochondritis dissecans, transient osteoporosis, bone bruises, or occult fractures [29].
  • A serpentine lesion within a well-demarcated border is a specific finding on MRI for osteonecrosis [29].
  • Bone edema on MRI is a common feature of osteoarthritis, osteonecrosis, cartilage injury, and transient regional osteoporosis [29].
  • MRI may identify the degree of articular cartilage injury, including chondrosis and full-thickness cartilage loss, as well as associated bone marrow edema and location [3].
  • MRI can identify patterns of meniscal injury by location, pattern (horizontal, longitudinal, radial, complex), and displacement [3].
  • MRI may suggest cruciate ligament injury through the presence of edema, intra-articular fluid, disruption of ligament fibers, and atypical ligament contour [3].
  • MRI is used to assess the continuity of the quadriceps or patellar tendon [3].
  • MRI may be used to assess the margin of resection for a neoplasm, identify vascular malformation, or define the location of nerves or vessels relative to popliteal cysts [3].
  • MRI is grossly overused in the arthritic patient population and is not indicated if the joint space is significantly narrowed on radiograph [23].
  • MRI is indicated when osteonecrosis is suspected in the arthritic patient population [23].
  • A systematic review quantified the diagnostic accuracy of MRI for detection of meniscal injury and ACL tear [20].
  • Compositional MRI techniques, including T1ρ, T2*, dGEMRIC, and gagCEST, are used for early recognition of cartilage degeneration [20].

Nuclear Medicine

  • Nuclear medicine involves labeled radionuclide injection followed by delayed imaging of gamma radiation, where areas of increased concentration appear bright or "hot" [3].
  • Nuclear medicine provides a nonspecific study that indicates the presence of an abnormality but does not define its etiology [3].
  • Increased radionuclide activity in bone may be a normal postoperative finding for up to 6 to 12 months after fracture repair or arthroplasty [3].
  • Technetium-99 (Tc-99) is a radionuclide that may help identify infection, neoplasia, occult fracture, bone healing, active phases of heterotopic ossification, implant loosening, or failure of osseointegration [3].
  • Gallium-67 (Ga-67) is a radionuclide that may help differentiate between aseptic and septic prosthetic loosening, requiring 24 to 72 hours for a complete study [3].

General Assessment

  • Assessment of the knee joint must combine physical examination with radiographic (including full-length alignment views) and MRI findings [30].
  • Radiographic evaluations are essential when diagnosing osteochondritis dissecans (OCD) lesions of the knee, though important aspects may be better seen with MRI [26].
  • Physical examination along with radiographic or advanced imaging findings must be used concomitantly to determine the source of symptoms and appropriate surgical intervention [7].

References

[1] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > Image KNEE INJURIES.

[3] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > I. Radiographic Evaluation.

[4] Aaos Comprehensive Orthopaedic Review 3. Anatomy and Biomechanics of the Knee > I. Anatomy.

[5] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 1 KNEE > ANATOMY (FIG. 4.1).

[7] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Introduction.

[9] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > II. Surgical Anatomy of the Knee.

[14] Aaos Comprehensive Orthopaedic Review 3. Knee Dislocations and Patellar Fractures* > I. Knee Dislocations.

[16] Campbell S Operative Orthopaedics 4 Volume Set. TRANSTIBIAL PULL-OUT REPAIR OF RADIAL OR MENISCAL ROOT TEAR > SYNOVIAL PLICAE OF THE KNEE.

[17] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Posterior Knee Anatomy.

[19] Campbell S Operative Orthopaedics 4 Volume Set. SINGLE-INCISION POSTEROLATERAL APPROACH TO THE LATERAL AND POSTERIOR MALLEOLI > POSTEROLATERAL AND POSTEROMEDIAL APPROACHES TO THE KNEE.

[20] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Annotated References.

[21] Aaos Comprehensive Orthopaedic Review 3. Biomechanics and Wear in Joint Arthroplasty > III. The Knee Joint.

[22] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Anatomy > Knee Kinematics.

[23] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 11 KNEE ARTHRITIS ASSESSMENT.

[26] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.

[27] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Anatomy > Imaging (Radiograph, MRI, CT Scan, Dynamic Versus Static) > Radiograph.

[29] Aaos Comprehensive Orthopaedic Review 3. General Evaluation of the Knee Patient > III. Osteonecrosis.

[30] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Summary.

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.