[CLINICAL PICTURE AND THERAPY OF PATELLAR LUXATION].
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Humans↗
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Medial patellofemoral ligament reconstruction: a novel technique using the patellar ligament.
In patients with chronic patellofemoral instability, more than 2 episodes of dislocation, and an anterior tuberosity trochlear groove of less than 20 mm as measured on computed tomography or nuclear magnetic resonance imaging, we have developed a technique for medial patellofemoral ligament reconstruction that uses a medial strip of the patellar ligament (PL). The incision started proximally at the level of the superior margin of the patella, centrally between the patellar medial margin and the medial epicondyle. A descending incision was then made, directed toward the superomedial margin of the tibial tubercle. We performed a plane-by-plane dissection up to the peritenon of the PL. With an osteotome, we could remove a 2-cm bone fragment concerning the medial third of the distal insertion of the PL or keep the distal end free. Using a No. 11 scalpel blade, we carefully detached the PL from the patella up to the transition between the proximal third and medial third of the patella. We placed the stitches between the periosteum and the ligament using FiberWire absorbable threads (Arthrex, Naples, FL) to safely rotate the graft. After that, we dissected the medial capsule and approached the femoral medial epicondyle. Then we placed a Krackow suture in the free tendon end using absorbable threads or anchored the threads into 2 holes that were previously drilled, and we secured the end with an absorbable interference screw or anchors. The fixation should be performed with the knee at 15 degrees to 30 degrees of flexion. Then we sutured the distal edge of the vastus medialis muscle to the graft, which bestows a dynamic component upon the reconstruction, and we immobilized the knee with a removable brace.
Arthroscopy↗
Arthroscopic lateral release for patellar pain or instability.
Forty-five arthroscopic lateral releases were reviewed with a follow-up from 2 to 6 years (average 4 years). Satisfactory results were obtained in 60% of the patellar pain group (20 knees) and 68.5% of the instability group (19 knees). The results in osteoarthrosis (6 knees) were unsatisfactory. Postoperative hemarthrosis was infrequent (2.2%). Unfavorable prognostic factors are an incomplete release with an insufficient postoperative passive patellar tilt in the pain group and more than five preoperative dislocations in the instability group. After failure of conservative treatment, a lateral release can be reasonably used in pain syndromes with a tight lateral retinaculum and lateral patellar tracking and in milder cases of instability.
Adult↗
Anterior cruciate ligament repairs in world class skiers.
From 1979 to 1984, 27 skiers who were either present or past members of the United States Ski Team or professional skiers had 30 ACL tears that were repaired primarily. Only two of the repairs were augmented with autogenous patellar tendon grafts. Five patients had complete knee dislocations, including tears of both cruciate ligaments. Nineteen patients had a concomitant extraarticular iliotibial band tenodesis. Twenty-seven knees (24 patients) were followed an average of 57.6 months postoperatively. Recreational skiing was resumed at 5.4 months on average, and in ski racing and pivot-requiring sports all but three patients resumed participation at an average of 9.1 months. In 78% of the knees there was pain-free function. Mild pain was reported in 19%, the majority of which (4/5) was related to vigorous activity. Of the total, only two knees were reported to have a sensation of giving way. On clinical examination 85% (23/27) had normal pivot shift examination with no evidence of abnormal motion. Four percent (1/27) had a 1+ test and 11% (3/27) had "glides." Arthrometer measurements revealed an average of 7.76 mm anterior displacement with 20 pounds of force on the knee with an ACL repair as compared to 5.56 mm on the uninjured knee. The laxity measurements of knees with repaired ACLs fell within the range reported for uninjured knees in the normal population. Five patients had reinjuries to the ACL at an average time of 28 months postoperatively, with two of five undergoing rerepair. Only one patient had an iliotibial band tenodesis to supplement the original ACL repair.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Anatomy of displacement of the insertion of ligamentum patellae in dislocation of the patella].
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Displacement, Psychological↗
Results and complications after arthroplasty with a totally constrained total knee prosthesis (GUEPAR).
A series of 51 patients (55 knees) with implanted GUEPAR totally constrained endoprosthesis was followed up clinically and radiologically for a mean of 5.0 years (range 1.5-11.8 years). Good relief of pain, increased range of knee movement and of walking capability were observed. There was, however, an unacceptable amount of severe complications. Three endoprostheses had to be removed and arthrodesis performed. Revision arthroplasty was carried out in 8 cases due to aseptic loosening of the prosthesis. In 25 cases lateral displacement or total dislocation of the patella was confirmed with tangential patellar X-ray projections. We suggest that the GUEPAR totally constrained total knee endoprosthesis and similar constructions should be chosen in only special cases, when aged patients have extremely damaged and unstable knee joints and non-constrained prostheses are not considered suitable.
Adult↗
[Quadriceps dysplasia and patellar tilt in objective patellar instability].
PURPOSE OF THE STUDY: Dysplasia of the vastus medialis, a well-known landmark of patellar instability, is difficult to point out pre-operatively. We propose the measurement of patellar tilt on the CT scans in order to appreciate abnormality. MATERIAL AND METHODS: We studied 3 well defined groups: 143 knees operated on for a true dislocation of the patella, either for the first time or a recurrent episode, 67 asymptomatic and nonoperated contralateral knees and 54 control knees. The patellar tilt in extension was measured on the CT-scan with the quadriceps relaxed and contracted. RESULTS: The results showed the increase of the patellar tilt as an characteristic factor of patellar instability (28.8 + 10.5 degrees against 11.8 degrees + 5.7 degrees in the control group). Patellar tilt was not a consequence of the dislocation because it was also significantly increased in the asymptomatic contralateral group (17 degrees + 9 degrees). Quadricipital contraction increased the patellar tilt only in the two groups of patellar instability (+ 6 degrees) and asymptomatic contralateral group (+ 13 degrees) but not in the control group (+ 1.6 degrees). The mean of the relaxed and the contracted quadriceps patellar tilt includes the dynamic trouble. We propose the threshold of 20 degrees to determine a pathological patellar tilt. In this case, sensibility is 90 per cent and the specificity is 91 per cent. In the other patellar instability factors, only severe trochlear dysplasias involved the patellar tilt. DISCUSSION: We think that the patellar tilt in extension is a landmark of a functional disorder of the whole quadriceps muscle more than the vastus medialis only. The mean of the relaxed and contracted quadriceps patellar tilt measures permitted to point out the border cases of this functional abnormality. This measurement is reliable and can be considered pathologic above 20 degrees. The results of Insall's muscular plasty were only symptomatic because this procedure could not correct the effect of the quadricipital contraction.
Adolescent↗
A chronically dislocating prosthetic patella. A case report.
A 63-year-old white woman was evaluated for a chronically dislocating right patella 6 months following total knee arthroplasty. At the time of our initial evaluation, her knee would not extend beyond 35 degrees and her patella was dislocated and irreducible. At arthrotomy, when the patella was everted, the patellar component was oriented with the facet ridge rotated 90 degrees to the trochlear groove of the femoral component. The patellar template guide indicated that the fixation pegs had been drilled properly, and thus, the patellar component had been assembled improperly during manufacturing. After dome-type patellar prosthesis replacement and proximal and distal extensor realignments were performed, 2 months post-revision the patient had a range of motion from 5 degrees to 95 degrees and ambulated with no patellar instability or pain.
Equipment Failure↗
[Results of Slocum-Larson patellar bridling].
The Slocum and Larson's surgical repair of the laterally dislocating patella is described. The results of 32 operations are discussed, follow-up-time was one to four years. 25 patients have no problems and have full activity in sports. Two patients have femoropatellar pain in the operated and two in the non-operated knee joint; so they had no normal athletic activity but they had no subluxation pain. One patient had a recent traumatic dislocation of the patella in landing a backward salto. We have obtained good results by the method of Slocum and Larson compared with various techniques of transferring tibial tubercle. This operation can be used also in young patients without disadvantages being a mere soft tissue procedure. The importance of lateral release and VMO-plastik is emphasized.
Adolescent↗
[Osteochondritis dissecans of the patella; pathological sketch of the patellar cartilage].
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Cartilage↗
Arthroscopically assisted proximal quadricepsplasty for patellar instability.
Arthroscopy has come to play a major role in the evaluation and treatment of patellofemoral instability. In fact, most patients sustaining a traumatic dislocation or recurrent subluxations are subjected to, at a minimum, an arthroscopic evaluation to assess intraarticular damage and patellar tracking.
Arthroscopy↗
A patient with Rothmund-Thomson syndrome and all features of RAPADILINO.
BACKGROUND: Mutations of the human helicase gene RECQL4 have been identified in a subset of patients with Rothmund-Thomson syndrome (RTS) and in children with the diagnosis of RAPADILINO syndrome (RAdial hypoplasia/aplasia, PAtellar hypoplasia/aplasia, cleft or highly arched PAlate, DIarrhea and DIslocated joints, LIttle size [>2 SDs below the mean in height] and LImb malformation, and slender NOse and NOrmal intelligence). While many features of the 2 genetic disorders overlap, poikiloderma--a hallmark of RTS--has been described as generally absent in RAPADILINO syndrome. OBSERVATIONS: We report herein a patient with RTS who carries a truncating mutation and a newly identified missense mutation of RECQL4. The proband uniquely developed all criteria of RAPADILINO in addition to his prominent skin findings. CONCLUSIONS: Patients with RTS may possess all features of RAPADILINO. Consequently, a genetic approach to RTS and RAPADILINO could be beneficial. This approach may provide a better understanding of the wide variety of related phenotypic findings and improve prognostics.
Abnormalities, Multiple↗
Revision arthroplasty with use of a total femur prosthesis.
BACKGROUND: Surgeons performing revision arthroplasties of the hip and knee are confronted with a growing number of patients with extensive loss of bone stock. Implantation of a total femur prosthesis is a possible method of treatment of such patients. The purpose of this study was to assess the functional outcomes and the complications associated with total femur replacements used in revision arthroplasty. METHODS: We evaluated the results associated with 100 total femur prostheses that had been implanted during revision arthroplasty in 100 consecutive patients without infection. The mean duration of follow-up was five years. The prosthesis was implanted because of a complication of a total hip replacement in seventy-seven patients, because of a complication of a total knee replacement in four, and because of a complication affecting the diaphysis of the femur in nineteen. Thirty-nine patients had sustained a periprosthetic fracture, usually in combination with loosening of the prosthesis, before the revision. The radiographs made at the time of the latest follow-up were evaluated for signs of loosening and material failure. The preoperative and postoperative function of the hip and knee was assessed according to the Enneking score. Five patients were lost to follow-up. RESULTS: Sixty-five patients (68%) had no complications. Deep infection was found in twelve patients (13%); dislocation, in six (6%); material failure, in three (3%); patellar problems, in two (2%); and peroneal nerve palsy, in one (1%). The mean preoperative Enneking score for hip function was 1.25 points, and it improved to 3.29 points postoperatively. The mean Enneking score for knee function was 2.09 points preoperatively and 3.29 points postoperatively. CONCLUSIONS: We believe that the total femur prosthesis is a useful implant for patients with extensive bone loss at revision arthroplasty. While the infection rate was high, the overall functional results for both the hip and the knee were rated as better than good with the Enneking classification.
Adult↗
[Tibial plateau fracture following oblique osteotomy of the tibial tubercle: a case report].
Oblique osteotomy of the tibial tubercle is a preferred technique in patellofemoral disorders, resulting in a satisfactory clinical outcome. However, postoperative fractures of the proximal metaphysis of the tibia may often develop. An incomplete fracture of the lateral tibial plateau occurred in a 23-year-old female patient following an oblique osteotomy of the tibial tubercle. There was no history of trauma. The patient had undergone two operations in the same knee due to patellar instability. She also had bilateral high congenital hip dislocation. The correct diagnosis could only be made by computed tomography. Complete union was obtained following six weeks of plaster cast fixation. Due to inherent biomechanical limitations, complications may arise following oblique osteotomy of the tibial tubercle even adequate care is given to the surgical technique.
Adult↗
Acute traumatic knee effusions in children and adolescents.
A prospective analysis was completed during a 6-month period to identify all patients, age 18 years or younger, who presented for evaluation of their knee effusion. There were 44 injured knees in 44 patients. There were a total of 55 diagnoses: 16 (29%) anterior cruciate ligament (ACL) injuries, 16 (29%) meniscal tears, 14 (25%) patellofemoral subluxations or dislocations, 3 (5%) medial collateral ligament sprains, 2 (4%) patellar osteochondral fractures, 2 (4%) retinacular injuries, 1 (2%) posterior cruciate ligament rupture, and 1 (2%) tibial eminence fracture. Girls had 11 of the 14 patellofemoral injuries; 58% of the girls had effusions secondary to patellofemoral pathology compared with 12% of the boys. Boys had 10 of the 16 meniscal tears and 13 of the 16 ACL tears. Fifty-two percent of boys had an injury to the ACL and 44% had an injury to a meniscus. In contrast, 16% of girls had an ACL injury and 32% had meniscal tears. ACL injuries, meniscal tears, and patellofemoral pathology accounted for 87% (48/55) of the diagnoses. Girls were more likely to have patellofemoral pathology; boys were more likely to have ACL and meniscal tears.
Acute Disease↗
Foot deformity in hereditary onycho-osteodysplasia.
A 30-year-old woman with hereditary onycho-osteodysplasia was examined. In addition to the classic tetrad of fingernail and toenail dysplasia, patellar aplasia, iliac horns, and radial head hypoplasia and dislocation, she also had scoliosis, proteinuria, and distinctive bilateral foot anomalies. The foot deformity consisted of a ball-and-socket ankle joint, valgus ankle, forefoot supination, and lateral subluxation at the tarsal-metatarsal joints. The literature showed that the radiographic findings of foot deformity in this dysplasia have never been reported in detail before. Evidence suggests that this distinctive pattern of deformity may be more common than previously appreciated.
Adult↗
[Computerized tomography assessment of replacement of the cruciate ligaments of the knee].
January, 1993, to December, 1995, we examined with CT 44 patients submitted to surgical replacement of knee cruciate ligaments, namely 18 anterior cruciate ligaments (ACL) and 6 posterior cruciate ligaments (PCL). ACL was replaced with a patellar tendon graft (Eriksson technique) in 23 cases and with a semitendinous graft (Lindemann-Bousquet technique) in 7 cases. The autologous new ligament appeared as a laminar structure of intermediate density. The tendon had been covered with a synthetic lining (Leeds-Kejo) in 10 of the above cases, while the new ACL graft was completely synthetic in 8 cases, which synthetic allografts appeared hyperdense relative to autologous new ligaments. PCL replacement had been performed with Augustine technique (patellar tendon graft in a tibial tunnel) in 3 cases, with Hughston technique (medial gastrocnemius graft in a medial condylar tunnel) in 2 cases and with a synthetic graft (Gore-tex) in 1 case. Twelve of 38 new ACLs were injured (7 Eriksson, 3 Lindemann-Bousquet and 2 synthetic grafts): the injured new ligament was enlarged and hypodense, or involved in atrophic absorption. The new ligament was partially calcified in one of the 3 patients with PCL replacement with a patellar tendon graft (Augustine technique). The bone bract was dislocated in the intercondylar notch in a patient submitted to Hughston surgery because of proximal disinsertion of the new ligament. The Gore-tex new PCL was sinuous in the proximal tract, with intra-articular calcified loose bodies. CT adequately depicted surgical results and diagnosed the new ligament injuries and other articular abnormalities. MRI is currently the gold standard in the multiplanar studies of the postoperative knee, but CT can be confidently used to identify ligament injuries and intra-articular calcified loose bodies.
Anterior Cruciate Ligament↗
[Treatment of major patellar instability. Results of the Fèvre-Dupuis operation].
In the treatment of recurrent subluxation and dislocation of the patella in adolescents and young adults, the authors describe a method consisting of: --a modified Roux procedure for internal transposition and advancement of the anterior tibial tuberosity; --the Lecène technic for over-the-top reinsertion of the vastus medialis on the lateral aspect of the patella. All the patients had a plaster cast for 10 days followed by rehabilitation until normal knee function was achieved. Stiff knees were mobilized under general anesthesia. Normal activity was progressively resumed 6 weeks after surgery. Out of the 31 patients (41 knees) available for objective follow-up evaluation, 26 were women and 5 men, with an average age of 19 years. The mean follow-up period was 9 and a half years with a minimum of 2 years and a maximum of 23. End results in terms of relief of pain, patellar stability and knee function were gratifying. Thirty knees were rated good, 8 fair and 3 poor. No recurrence of subluxation or dislocation was found.
Adolescent↗