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Fifteen patients with patellofemoral pain resulting from patellar malalignment had coronal plane osteotomy of the patella. Patients were followed for an average of three years, and all results except one were favorable. The relief of pain was attributed to both the reduction of intraosseous pressure including associated biological adaptations and the mechanical realignment of the patella.
Subluxation of the patella may produce pain and instability in young people. However its classification, diagnosis and treatment are controversial. We have used computerized tomography (CT) to measure the amount of lateral shift of the patella and the angle of tilt to the femur in patients with subluxation. The mean lateral shift was 31.4% and the angle of tilt 31.8 degrees. These values are significantly greater than those obtained from conventional axial radiographs or in arthrographic axial views. We have obtained interesting evidence that the rate of lateral shift apparently increased on voluntary contraction of the quadriceps muscle (Q-contracted). With the quadriceps contracted, the mean rate of the lateral shift in the affected knees showed a significant increase (+27.7%) compared to that in normal knees (+14.0%). We have reviewed 40 knees treated by operative realignment with a mean follow-up of 27 months. The mean rates of lateral shift measured from CT-image in the knees before operation improved significantly to the normal range at follow-up, both with the quadriceps relaxed and contracted. The results evaluated by Insall's criteria were "excellent" in 13 knees; "good" in 22; "fair" in 3 and "poor" in 2. The satisfactory group (those with excellent and good results) revealed an improvement in lateral shift when the quadriceps was contracted, while the unsatisfactory group (fair and poor results) did not.
The methods of Insall and Salvati, Blackburne and Peel, Caton and Laurin of assessing the vertical position of the patella, were applied on 200 normal knees. The indices for Insall and Salvati's, and Blackburne and Peel's methods were 1.07 +/- 0.25 and 0.78 +/- 0.19 respectively, independent of sex and flexion of the knee. The measurements for Caton's index were 0.95 +/- 0.24 and 0.88 +/- 0.22 at kneeflexions of 45 degrees and 90 degrees. Laurin's method was insufficient as it showed 50% of the patellas to be high riding. The different methods were compared. The technique of Insall and Salvati was a reliable and applicable method, and is therefore recommended for routine use.
The present paper reports a case of osteo-onychodysplasia (nail-patella syndrome). There are very few descriptions of this syndrome in the orthopaedic literature, possibly because it is rare for the morphological changes in the knee and the associated abnormalities to require or be amenable to treatment. In the present case an accidental sprain of the right knee caused recurrent dislocation of the patella that necessitated surgical intervention.
The author explains how to use an accessory allowing axial patella roentgenography without patient helping with different angulations: 30 degrees, 60 degrees and 90 degrees. Radiographs are realised with low rate contraction of quadriceps and immobilisation, with two femoro-patella joints on the same view with simple table and moving X-ray tube.
Osteochondritis dissecans is a disorder which rarely involves the patella. It must be differentiated from chondromalacia, lateral marginal fracture due to direct injury, medial facet osteochondral fracture secondary to traumatic lateral dislocation and a dorsal defect of the patella. I report a patient in whom computed tomography (CT) helped confirm the diagnosis. Although usually diagnosable from plain films, in difficult patients CT should be considered.
The Elmslie method using a soft-tissue strip aims at realigning the extensor mechanism in the same way as the Elmslie-Trillat operation in adults. We feel that the main cause of dislocation or subluxation of the patella is to be found in incorrect alignment of this mechanism. We feel that the Q angle should especially be correct with regard to knee stability during rotation. This angle should not be neutralized or even inverted. In young, growing patients, as compared to adults, excess stress on the medial side due to medial displacement of the tuberosity will be compensated for by increasing valgus of the knee joint. Analysis of the potential risks involved in this pretuberosity operation led us to the conclusion that there is no risk of early epiphysiodesis or bony recurvation, and no risk of patella baja or osteochondrosis of the tuberosity. The functional results are so far very satisfactory (13 of 17 reexamined cases continue to be involved in sports or have taken up sports); this is particularly rewarding if we consider that the operation is not technically demanding and may even be undergone by ambulatory patients.
Degeneration of the cartilage on the under surface of the patella is shown to be the most frequent cause of "internal derangement of the knee" (63%). The axial view of the patellofemoral joint in 4 angles of flexion constitutes the procedure of choice for diagnostic exploration of patellar cartilage with, perhaps, the restriction for the medial compartment where arthroscopy is probably preferrable. The information obtained from single contrast arthrography of the patellofemoral joint has contributed greatly to the understanding of the sometimes confusing problem of chondromalacia of the patella. It has given an anatomic basis to the patellar syndrome and has served as a basis for a precise typographic system of classification. From this, we have been able to correlate localization and etiology which has then allowed logical solutions to be proposed for each group, based upon biomechanical considerations in both the frontal and saggital planes of the knee.
The nail--patella syndrome is a rare, inheritable disease of the connective tissue in which multiple osseous abnormalities are associated with dysplasia of the nails. Renal dysfunction is found in 25--42% of cases and varies from asymptomatic proteinuria to renal failure. This paper describes a patient with nail--patella syndrome and terminal renal disease requiring transplantation.
In the human patella from the 4th month up to the birth were examined contents and surrounding structures of vascular channels. Except the articular area the cartilage of the patella is covered by the perichondrium. From here mesenchym and blood vessels enter, and penetrate into the cartilage by forming channels. Dependent on the stages of development the construction of cartilage around the channels is different in comparison with other territories. The findings will be compared with the results from the channels in the cartilaginous anlage of different bones.
The author describes a modification of surgical procedure described by Heusner for the management of habitual dislocation of the patella. The lateral patellar retina culum was divided, the medial retinaculum plicated and the semitendinosis transplanted subcutaneously and attached to the patella through a tunnel. 12 cases have been operated on with 9 satisfactory results but with three recurrences.
The material of this investigation consisted of 104 patients (37 males and 67 females), treated for dislocation of the patella at the Department of Orthopedics in Lund during 1975-1977. The patients were examined clinically and radiographically in order to identify the etiologic importance of trauma, generalized joint laxity, and an anatomically abnormal patellar articulation. All patients were examined for generalized laxity, other orthopedic conditions, relatives with patellar dislocation or congenital dislocation of the hip, dislocation frequency, bilateral patellar dislocation, age and the nature of the trauma at initial dislocation, incidence and type of articular fractures associated with patellar dislocation, and three radiographic parametres of anatomically abnormal patellar articulations. Generalized joint laxity was observed in two thirds of the patients, frequent dislocations in one half and bilateral dislocations in one third. In half of the patients the initiating trauma was insignificant, and one third had avulsion or osteochondral fractures. The majority had definite anatomic abnormalities but patella alta was observed in only one fourth of the patients. The material was subjected to an analysis of the covariation of etiologic factors operating in patellar dislocation. On this basis the material was classified in four grades of increasing patellar instability, from Grade I with neither laxity, nor increased Insall index, to Grade IV with both these factors. With increasing patellar instability the frequency of recurrent and bilateral dislocations increased whereas the degree of trauma and incidence of fractures decreased. The type and degree of anatomic abnormalities were correlated to the different grades of patellar instability. The classification of patellar instability proposed here should permit more precise evaluation of treatment of patellar instability, and, eventually, provide a basis for the choice of therapy in patellar dislocation.
Of five patients with a dorsal defect of the patella, four were followed for seven to thirteen years. The lesion causes a persistent change in the radiographic appearance of the bone and there may be some residual discomfort in the involved knee. It is best demonstrated on tomograms and on posterior oblique radiographs of the patella. The cause of the defect is unknown and its pathology has not been clearly defined.
Nontraumatic, hemotogenous osteomyelitis is a childhood disease uncommonly encountered and rare in the patella. The initial signs are usually intraarticular, because of the sterile effusion. The primary pathology in the patella is easy to overlook. The infection generally does not penetrate the joint cavity and most cases can be treated conservatively, or by local debridement. Arthrotomy is not necessary and could involve the joint with the infection.
In a retrospective review of 184 knees treated for surgically diagnosed chondromalacia of the patella, the average follow-up period was 3.9 years. The treatment rendered included trephine and drilling in 71 knees, facetectomy in 57 knees, shaving in 35 knees, and a combination procedure in 21 knees. Knees were graded as 2, 3, or 4, depending on the depth and severity of the lesion. The best results were in Grades 2 and 3 disease treated by trephine and drilling or facetectomy. Six patients required further patellar surgery during the follow-up period. The purpose of surgical treatment of the patellar articular surface is to relieve pain and preserve the mechanical advantage of the patella for normal knee function.
40 patellae of different age groups were examined by X-ray and histology. X-ray changes found in the cartilage, corticalis and cancellous bone were in full agreement with histological findings. However, more than a quarter of the patellae were found to be affected by microscopic fibrillation of the surface of the cartilage without any demonstrable changes in the cartilage proper. In all those cases except one, however, roentgenograms helped to detect changes in the corticalis or also cancellous boneof the lamellae such as are associated with bone reconstruction, mostly in the form of subchondral bone lamella dilatation and of the thickening of adjacent cancellous bone trabeculae.
Wedge recession is a method which utilizes the geometry of similar triangles to recess an articular wedge into the underlying bone. This concept has been applied to congenital luxating patellae in the dog. A trochlear wedge recession deepens the femoral trochlea and provides stability to the patella. Preliminary trials of the procedure in dogs produced excellent results.
Arthroscopically controlled lateral release for subluxating and dislocating patellae was reviewed in 93 knees (79 patients) at an average of 48.7 months follow-up. Of the patients, 92 % reported significant subjective improvement. Eighty-nine per cent of males and 69% of females were rated good or excellent by objective criteria. Failure to maintain good quadriceps muscle strength was the major reason for fair and poor results. Of 14 knees with dislocations, none had a recurrence after surgery. Patellar shaving was not done in any of the knees. The results of lateral release did not correlate with the severity of chondromalacia patellae. Complications and morbidity were significantly reduced by this outpatient procedure. Experience in endoscopic techniques is an important prerequisite. In the properly selected and motivated patient, this procedure offers an effective alternative to major patellar realignment procedures.