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An arthroscopic procedure of excision of damaged cartilage and drilling the subchondral bone plate for treatment of chondromalacia patellae is described. Satisfactory results and absence of major complications are reported in a preliminary, short-term series of 24 cases of symptomatic posttraumatic chondromalacia patellae, with a mean follow up of 12 months.
Patella tendon rupture is a debilitating injury that often occurs in the setting of preexisting tendon degeneration. Prompt diagnosis and treatment is essential to prevent retraction of the patella with subsequent adhesions and quadriceps contractures. In the setting of a chronic rupture, augmentation with hamstring tendons or allograft reconstruction generally is necessary. Patients who undergo delayed repair are at risk for a compromised result secondary to loss of full knee flexion and decreased quadriceps strength, although a functional extensor mechanism is likely to be reestablished. Overall the results of chronic repair are less satisfactory than the acute repair, but still provide an extensor mechanism for the patient and thus provide function.
Fifty patients who had an arthroscopic anterior cruciate ligament reconstruction for chronic insufficiency were reviewed at an average of 13.6 months following surgery. Among these patients, 32% complained of anterior knee pain that interfered with daily activities. Radiographic patella infera was present in 12% of patients using the Insall-Salvati ratio and in 16% using the Blackburne-Peel ratio. Radiographic patella infera did not correlate with the clinical problem of postoperative anterior knee pain. However, loss of knee extension of greater than 5 degrees correlated highly with pain (p=0.002).
The Meier-Gorlin syndrome, first described by Meier and Rothschild [1959: Helv Paediatr Acta 14:213-216] and further delineated by Gorlin et al. [1975: A Selected Miscellany, p 39-50], is characterized by short stature, slender body build, craniofacial anomalies, microtia, delayed skeletal development, hypogonadism, and absence of the patellae. It has also been called the ear-patella-short stature syndrome [Boles et al., 1994: Clin Dysmorphol 3:207-214]. We report on two brothers with Meier-Gorlin syndrome, the younger of whom was more severely affected. Both patients had severe deafness and congenital labyrinthine anomalies, which have not previously been described as features of this syndrome. The neuromotor and mental development of these patients was adversely affected by late diagnosis, deafness, and their sociocultural environment, but their cognitive ability fell within the range observed in other Meier-Gorlin patients. Neuroradiographic imaging and functional inner ear investigations are recommended in the diagnostic workup of this rather specific, probably autosomal recessive mental retardation syndrome with multiple congenital anomalies.
In the study of the efficacy of internal fixation with tension band of musculofascial tendon in the treatment of fracture of patella, 52 cases were reported. After a following-up of 6 months to 13 months the bone healing was observed, in 7.5 weeks in average, and the function of the knee joint had recovered to normal or almost normal. It was concluded that the treatment of fracture of patella by internal fixation with tension band from musculofascial tendon was a ideal and practicable method.
Two hundred three fractures of the patella in 200 patients were treated by tension band wire fixation using one or several wire loops and 2 longitudinally directed Kirschner wires. They were reviewed with a mean follow-up of six years (range 1 to 10 years). There were 143 men and 57 women. Age at operation averaged 36 years (range 18 to 83 years). The most frequent etiology was a road traffic accident. The fractures were simple in 35.5%, slightly comminuted in 37%, and very comminuted in 27.5% of cases. Thirty-four fractures were open, and there were other associated fractures in 35 cases (17%); 12 fractures (6%) were seen in polytrauma patients. The operation was performed on the first day in 63 cases (31.5%), between 2 and 8 days following trauma in 112 cases (56%), and after the 8th day in 25 cases (12.5%). The authors used 2 Kirschner wires in 81 cases (40%), 3 in 73 cases (36%), and more than 3 in 49 cases (24%). A single wire loop was used in 99 cases and a modified tension band wiring in 104 cases; passive mobilisation of the knee was started on the second day after operation, and weight bearing was allowed after five days, except when there were associated lesions. The complications were sepsis in 11 cases (5%), loosening of material in 20 cases (10%), malunion in 9 cases (4.5%), nonunion in 8 cases (4%), femoropatellar osteoarthritis in 17 cases (8.5%). The results were excellent or good in 169 cases (83%), and fair or poor in 34 cases (17%). The authors recommend this operative technique which allows good anatomic reconstruction of the patella, early mobilisation of the knee and early weight-bearing with a high rate of consolidation.
A 77-year-old woman with severe varus and flexion deformity of both knee joints, hypertension, and arteriosclerosis underwent bilateral total knee arthroplasty. Six weeks after the operation on the right knee and four months after the operation on the left knee, osteolysis of the patellas was seen on the radiographs. Three years after the operations, the lateral and inferior poles of both patellas were sclerotic and displaced. There was no knee pain and no extension lag throughout the follow-up period. This case suggests that the prognosis of patellar osteonecrosis after total knee arthroplasty is good if the continuity of the retinaculum and the extensor mechanism are preserved, and if instability of the knee does not occur.
BACKGROUND: In review of the literature there is no standard treatment of acute- as well as recurrent dislocation of the patella. Most investigations are retrospective or not randomised. Approximately 1500 patients/year with the diagnosis luxatio patellae are seen in Danish hospitals. METHODS: Using a questionnaire we wished to find out how these patients were treated in Danish orthopaedic departments. RESULTS: We found that there was no consensus on the treatment of patellar dislocation. CONCLUSION: We concluded that there is a need for prospective randomised studies involving a large number of patients, with a long follow up time.
At least 16 cases of posttraumatic chondromalacia of the patella out of a total of 79 patients operated between 1968 and 1971 were diagnosed on the basis of a questionnaire and follow-up examination. The clinical findings and delineation of this complaint from femoro-patellar osteoarthritis are discussed. The diagnosis was confirmed by arthroscopy in 2 patients. The significance of cartilagenous damage due to direct contusion is pointed out. The mechanisms which result in a degradation of the cartilagenous layer in the weeks following the accident are mentioned. The therapeutic consequences for the treatment of fractures of the patella are as follows: One must aim at exact bony reduction. Macroscopically damaged parts of the cartilage should be removed. Indication to partial patellectomy should be on a broad basis. A long term treatment with salicylic acid or Chloroquin-both of which are said to prevent enzymatic degradation of cartilage-should be considered.
Two hundred knees of 100 Chinese cadavera were studied with reference to factors which have been implicated in the etiology of chondromalacia of the patella. The findings were as follows: chondromalacia of the patella was less common in Chinese than in Europeans, did not always start in the medial patellar facet, and showed no relationship to the presence of abnormal menisci or to the anatomical characteristics of the medial femoral condyle which have been suggested as causative factors.
PURPOSE: To compare the femorotibial rotation, the patellar translation, the hip-knee-ankle angle and the Q-angle in patients with a dislocation of the patella with those of healthy volunteers. Further, the clinically measured Q-angle was compared to that measured by radiography. MATERIAL AND METHODS: A system for measurement of patellar variables was previously developed and applied to 80 healthy volunteers. In the present study, 28 patients (20 women, 8 men) with dislocation of the patella were examined bilaterally. Fourteen patients had habitual dislocations (20 affected knees) and 14 patients traumatic dislocations (17 affected knees). In 20 patients the clinical Q-angle was measured bilaterally by an orthopaedic surgeon and in 9 of these patients also by a second independent orthopaedic surgeon. RESULTS: The most striking finding was that dislocating knees in both groups showed a smaller Q-angle than the healthy knees. Further, the habitual group showed greater relative rotation between the tibia and the femur and an increased patellar translation compared to the traumatic group and to the healthy volunteers. There was a poor correlation between clinical and radiographic measurements of the Q-angle and no correlation was found between two independent clinical measurements. CONCLUSION: Surgical operations aiming at decreasing the Q-angle should be challenged.
Among the factors that influence the patellofemoral alignment and stability, the position of the tibial tubercle was evaluated using plain radiographs and computed tomography (CT). Radiographs of the Q-angle with the knee in full extension and quadriceps muscle relaxed showed that mean Q-angles in the dislocation or subluxation group and control group were 13.8 degrees and 14.3 degrees, respectively. The major reason for this deceptive measurement was a patella positioned laterally in the dislocation or subluxation group. Better estimation was made with the modified Q-angle measurement by using the most concave point of the intercondylar notch as a reference point instead of the center of the patella. By overshadowing CT images of the levels of the patellofemoral joint and the tibial tubercle, it was possible to evaluate the location of the tibial tubercle in relation to the femoral trochlea. Both the angular measurement (lateral deviation angle [LDA]) and the distance measurement (lateral deviation index [LDI]) showed that the tibial tubercle in the dislocation or subluxation group was rotated externally and shifted laterally (LDA, 36.3+/-7.0 degrees and LDI, 30.1+/-5.6) compared with the control group (LDA, 20.2+/-7.1 degrees and LDI, 15.1+/-5.6). Further study is warranted to elucidate the exact mechanism of recurrent patellar dislocation and subluxation.
The new patella prosthesis design is based on an anatomical study of 80 arthritic patellas and on the normal patellofemoral contact area under loading in cadaver knees. The metal dome-shaped prosthesis is attached by a central pin. The patellar prosthesis is constructed either of metal or plastic for use in combination with the Hospital for Special Surgery design of total knee prosthesis. Methylmethacrylate is used to supplement the fixation after resection of the abnormal patellar articular surface. The fixation tests gave excellent laboratory results for contact area and stability. The prosthesis has been used in 19 cases with encouraging early results.
Nineteen knees were treated for recurrent subluxation or dislocation of the patella by lateral and distal transfer of the vastus medialis with or without release of the lateral retinaculum. Fifty-eight per cent has good or excellent and 42 per cent had poor results after a mean follow-up of twenty-nine months. The factors that predisposed to failure were genu valgum greater than 15 degrees and, to a lesser extent, palpable synovitis associated with symptomatic chondromalacia patellae.
Fractures of the patella in childhood and adolescence are a rare occurrence, and they are differentiated from those occurring the adult. Between 1975 and 1995, 76 cases of fracture of the patella in patients aged under 15 years were treated at our institute. A mean clinical-radiographic follow-up of 2 years was available for all of the patients; 18 patients were followed-up after a considerable amount of time (mean 18 years). After analyzing the specific features that distinguish there fractures when they affect a subject who is still growing, the authors report the results obtained and the short and long-term complications observed.
We developed a new patella-cutting guide that simplifies proper alignment and enables resection of the correct thickness of bone. This guide consists of a central shaft, two support frames, and a ring. The ring consists of upper and lower disks, with a slot between the disks. The central shaft and the lower disk have holes for fixation pins. The distance from the distal end of the central shaft to the lowest level of the slot is 8 mm. Bone of the same thickness as that of the patellar component can be automatically resected using this guide. A feeler gauge is inserted through the slot, and the periarticular region is felt. This procedure enables the guide to be set at the correct angulation. A laboratory study using fresh-frozen cadaver patella specimens and a clinical study showed that proper alignment and proper resection were achieved using this guide.
The fracture of the biggest sesamoid bone patella is encountered at a rate of 1% of all skeletal injuries. Partial patellectomy is advised in the treatment of comminuted fractures of patella. In this retrospective study, we evaluated 18 of 25 patients who had partial patellectomy in our clinic between 1986-1997. Five patients were female (%27.8) and 13 were male (%72.2). The mechanisms of injuries were as follows: 11 (%61) motor vehicle accidents; 4 (%22) falls from flat-roofed house; 2 (%11) gunshot; and 1 (%5) subsidence. The mean age of the patients was 34.3 (range, 13-65). Ten left (%55) and eight right (%45) partial patellectomy were performed. Ten (%55) patients had also additional pathologies. The median follow-up time was 5.2 years (range, 2-11 years). Patients were very well in the last follow-up. According to Cincinnati Knee Score, which was improved by Noyes, 5 patients (%30) had excellent, 8 (%42) good 3(%17) moderate and 2 (%11) bad results. In conclusion, in the following years, enlargement in patellar articular surface and ossification, which is developed compensationally in the extensor mechanism may be detected and misevaluated as osteoarthrosis. Hence, we determined that they had not restricted knee joint functions in our cases.
The use of autologous bone-tendon-bone grafts for reconstructive surgery of the anterior cruciate tendon is a widely diffused technique. Fracture of the donor patella constitutes an uncommon complication. It is the purpose of this study to present the clinical case of a patient submitted to reconstructive surgery of the anterior cruciate ligament where the existence of asymptomatic nonunion of the patella was by chance observed.