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PubMed2002

Two-stage reconstruction with autografts for knee dislocations.

Traumatic knee dislocations are severe injuries that involve damage to the anterior cruciate ligament, the posterior cruciate ligament, and the lateral or medial ligamentous structures. There are no established methods of treatment. The objective of the current study was to report the clinical outcome of a two-stage autologous reconstruction on nine knees (eight patients). The mean followup was 40.1 months. The first stage of the reconstruction was done at a mean of 2 weeks after the injury, and the posterior cruciate ligament was reconstructed by an arthroscopically assisted technique using contralateral autogenous hamstring tendon as the graft material. Three months later, the second stage of the reconstruction was done for the ligaments that had not healed with conservative treatment. Arthroscopically assisted anterior cruciate ligament reconstruction was done on all of the knees using the ipsilateral autogenous hamstring tendon or bone-patellar tendon-bone as the graft material. At the same time, a medial collateral ligament reconstruction using an autogenous semitendinosus tendon was done on one knee, and reconstruction of the posterolateral ligamentous structures using a biceps tendon was done on three knees. Each of the knees that was reconstructed was capable of full extension, and the mean degree of passive flexion was 139.5 degrees +/- 5.2 degrees. The mean side-to-side difference in anteroposterior total laxity (KT-1000 arthrometer, manual maximum) was 2.3 +/- 1.9 mm. None of the knees had lateral or medial instability. All of the injured ligaments were able to be reconstructed with autografts, and severe contracture was able to be prevented. A good clinical outcome can be achieved when two-stage reconstruction is used for traumatic knee dislocations.

Adult↗
PubMed1991

[Computerized tomography in instability of the femoropatellar joint].

Compared with normal X-ray examination, a CT scan can give more information about patellar alignment, especially close to full extension of the knee-joint. We compared the normal knee-joints of 10 volunteers with the knee-joints of 15 patients (19 recurrent luxations, 5 habitual subluxations). We were able to distinguish between instabilities with and without changes seen on the X-ray pictures, making it possible to develop a systematic concept of treatment. In the case of recurrent dislocation with radiologically visible instability, surgical repair is the treatment of choice, while for habitual subluxation without radiologically visible instability the primary treatment of choice is conservative therapy with physiotherapy and muscle training. This is successful in most cases. If physiotherapy fails surgical repair is the next step in treatment. This dynamic type of investigation (the patella is stabilized by tension of the quadriceps femoris muscle) makes an objective judgement of the result of therapy possible.

Adult↗
PubMed1994

[Classification of patellar fractures].

The AO-Classification of patellar fractures, introduced 1979 is based on difficult radiomorphologic criteria. It has never been widely accepted. The suggested classification should allow a clear therapeutic concept. The prognostic value will be analysed in a further study.

Fracture Fixation, Internal↗
PubMed2000

[Arthroscopic assessment and clinical correlation of femoro-patellar tracking. Apropos of 116 knees in 115 patients under 40].

PURPOSE OF THE STUDY: The dynamic study of the patello-femoral joint is of outstanding interest in unexplained anterior knee pain syndrome. Accuracy of information provided by video-arthroscopy is of concern due to its technical conditions. Serum inflow favors the natural patellar tendency to shift laterally (mean value, 7 degrees ). Absence of active quadriceps muscle contraction under anesthesia and use of a tourniquet act conversely. The aim of this study conducted in less than 40 year-old patients, was to correlate retrospectively arthroscopic evaluation of patello-femoral tracking and trochlear centralization measured during conventional "inflow" procedure, with patella related pain syndrome and its outcome. MATERIAL AND METHODS: The study group included 116 knees in 66 male and 49 female patients (1 bilateral). Mean age at arthroscopy was 26 years (range, 12 to 40 years). According to pre-arthroscopic clinical data, knees were broken down into 3 study groups: Gr-T (Test, painless patella), 50 knees with meniscal and/or ligament injury: Gr-PRP (Patella Related Pain but no dislocation), 55 knees: Gr-DLC (patella DisLoCation), 11 knees. Arthroscopic technique was the following: general anesthesia, high-proximal pneumatic tourniquet (40mmHg), single antero-lateral portal and serum inflow by simple gravity (2m). The minimum flexion angle that was necessary to obtain de visu a perfect centralization of the patella dome into the trochlear groove was systematically measured before any arthroscopic procedure was performed. RESULTS: Average value of the Flexion Angle providing perfect Centralization (FAC) in the "serum inflow" arthroscopic situation was 39 degrees in Gr-T and 52 degrees in Gr-PRP; this difference was highly significant (p <.0001). Patella centralization could not be achieved despite maximum possible flexion in 5 of the 55 PRP-knees and in 9 of the 11 DLC-knees. FAC value > 65 degrees correlated significantly (chi2, p=0.0001) with patella related clinical symptoms (pain and instability, groups PRP + DLC) and indicated patellar maltracking. In the PRP-group, an "FAC value > 65 degrees" showed a low sensitivity (0.34), but high specificity and positive predictive value of 0.98 and 0.95, respectively. DISCUSSION AND CONCLUSION: Arthroscopic examination for patello-femoral tracking can provide measurable information on the FAC angle, that is reproducible under precise technical conditions. Its diagnostic value in unexplained anterior knee pain versus information provided by conventional imaging, and their respective effectiveness-risk and -cost relations could be the purpose of future prospective studies.

Adolescent↗
PubMed2002

Reconstruction of the lateral patellar retinaculum following lateral release: a case report.

The recognition and treatment of iatrogenic medial subluxation of the patella following lateral retinacular release may be difficult. The diagnosis even by magnetic resonance imaging may be difficult. The use of a medial patellar stabilising brace may be helpful in the diagnosis, alleviating symptoms in the short term and to gain the confidence of the patient. A technique of direct repair that was used successfully is described in a case report.

Adult↗
PubMed1990

Evaluation of patients with persistent symptoms after lateral retinacular release by kinematic magnetic resonance imaging of the patellofemoral joint.

The arthroscopic lateral retinacular release is typically performed to treat patellar pain and instability. This procedure was previously considered to be relatively benign with a low associated complication rate. However, a high incidence of medial subluxation of the patella was recently reported in patients with persistent symptoms after lateral retinacular release. Because the use of physical examination criteria may not always be sufficient to assess patellar alignment, 40 patients (43 knees) were evaluated by the newly developed technique of kinematic magnetic resonance imaging of the patellofemoral joint. One (2%) patellofemoral joint had normal patellar alignment, 10 (23%) had lateral subluxation of the patella, 1 (2%) had excessive lateral pressure syndrome, 27 (63%) had medial subluxation of the patella, and 4 (9%) had lateral-to-medial subluxation of the patella. Seventeen of 40 patients (43%) with unilateral arthroscopic lateral retinacular releases had medially subluxated patellae on the unoperated joints. Because patellar malalignment commonly affects bilateral joints, medial subluxation of the patella may have been present before the lateral retinacular release but was not recognized in these patients.

Adult↗
PubMed1993

Long-term complications after total knee arthroplasty with or without resurfacing of the patella.

The long-term complications related to the patella were retrospectively evaluated for 891 knees (684 patients) that had had a total arthroplasty, with or without resurfacing of the patella, with use of an unconstrained, condylar, posterior-cruciate-preserving prosthesis. The study population comprised two groups of patients who were similar in size, age, sex distribution, and diagnosis. One group (396 knees [303 patients]) had had a total knee arthroplasty with patellar resurfacing and the other group (495 knees [381 patients]) had had the same procedure without resurfacing. The average duration of follow-up was six and one-half years (range, two to fifteen years). The decision to resurface the patella was based on subjective inspection of the articular surface and on assessment of patellar tracking at the time of the operation. Resurfacing was performed if there was loss of cartilage, exposed bone, gross surface irregularities, or tracking abnormalities. Complications occurred an average of three years (range, immediately postoperatively to nine years) after the operation in the group that had had resurfacing and an average of four years (range, immediately post-operatively to ten years) postoperatively in the group that had not had resurfacing. In the group that had had resurfacing, there was loosening of the patellar component in five knees, patellar subluxation in four knees, fracture of the patella in three knees, rupture of the patellar tendon in three knees, and chronic peripatellar pain in one knee. In the group that had not had resurfacing, the complications included patellar subluxation in five knees, rupture of the patellar tendon in two knees, and chronic peripatellar pain in fifty-one knees.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1979

Proximal and distal reconstruction of the extensor mechanism for patellar subluxation.

Proximal and distal reconstruction of the leg extensor mechanisms has been developed and performed in 346 cases over a period of 25 years. Proximal extensor mechanism reconstruction produces very satisfactory results in over 70% of cases and continues to be the basic principle of surgical treatment for patellar subluxation. In patients with Q angles (angle between line of the quadriceps force and the direction of the patellar tendon) greater than 10 degrees distal reconstruction (patellar tendon transfer) is done in addition to, not in lieu of, the dynamic proximal reconstruction. Treatment of the chondromalacia developing secondary to altered extensor mechanism mechanics can be by simple chondrectomy provided that the causal mechanical abnormalities are modified.

Humans↗
PubMed1988

Patellar subluxation following plica resection.

In this paper, a case of patellar subluxation following the excision of a medial plica is presented. The biomechanical relationship between the medial plica and the patella is discussed and the need for a complete preoperative evaluation of the patient with a symptomatic plica is emphasized.

Child↗
PubMedDate not supplied

The correlation of canine patellar luxation and the anteversion angle as measured using magnetic resonance images.

Measurements from magnetic resonance (MR) images can be used to examine the anteversion angle (AT-angle) and its influence on the lateromedial or mediolateral luxating forces on the patella. The AT-angle of the femoral neck was measured with the aid of MR imaging in 45 pelvic limbs without patellar instability, in 33 limbs with patellar luxation and in 6 limbs with rupture of the cranial cruciate ligament. The limbs with medial patellar luxation were divided into three groups based on clinical examination. The mean (range) AT-angle was 7.6 degrees (0 degrees to 24 degrees) in the "normal" group, 8.6 degrees (-10 degrees to 29 degrees) in the group "grade II," and -0.4 degrees in the group "grade III" (-28 degrees to 12 degrees). A mean (range) AT-angle of 4.8 (-4 degrees to 11 degrees) was measured in the pelvic limbs with rupture of the cranial cruciate ligament. Compared to literature that described AT-angles based on radiographs of normal limbs, reduced AT-angles were found in this study due to different lines of measurement of the femoral neck. This study documents that the AT-angle of the femoral neck does not influence patellar instability. This study also demonstrates that MR images can be used to make exact measurements of the canine AT-angle that represent the true anatomy of the femoral neck.

Animals↗
PubMed1987

The quadriceps function in patellofemoral disorders. A radiographic and electromyographic study.

The influence of quadriceps contraction on patellar alignment was investigated in tangential views of 31 patients with patellofemoral complaints and compared with 25 controls. The congruence angle decreased significantly following quadriceps contraction in patients with patellar subluxation in contrast to those with chondromalacia and normals. Electromyography (EMG) of the vastus lateralis (VL) and vastus medialis obliquus (VMO) during maximal quadriceps contraction was obtained prior to and after 3 months of isometric quadriceps exercises in 15 knees with patellar subluxation and in 11 with idiopathic chondromalacia of the patella. The EMG after 3 months revealed an increase in the activity of both VL and VMO only in patients with patellar subluxation, but the muscular balance of the patella remained unchanged. Only seven patients were improved after 3 months. A more selective training of the VMO is proposed.

Adolescent↗
PubMed1995

A new surgical method for canine congenital patellar luxation.

Canine patellar luxation is seen in toy and miniature breeds, and in the majority of cases the problem is medial patellar luxation. When the luxation is left alone, it causes deformity and disorder in the growth of the affected limb. In severe cases, the limb may cease to afunction. Early surgical correction is therefore essential, but the owners are not able to detect the disorder at an early age and surgical intervention in most cases will take place after 6 months of age. The authors were able to have the opportunity to operate at an earlier age by educating breeders and owners. Various techniques have been developed and implemented to correct this disorder with varying therapeutic results. The authors have devised a unique surgical method which has been applied to the numerous cases with good results since 1985. The procedure is to make a longitudinal groove on the medical cortical bone of the tibial tuberosity along the tibial crest, and to place small pieces of artificial ceramic bone or autoplastic bone grafts in the groove, thus laterally transposing the tibial tuberosity and crest. This method makes it possible to put the quadriceps muscles of the thigh, the patella and the patellar ligament in the correct alignment over the femoral trochlea. It is considered appropriate to conduct this operation at 1.0-3.0 months of age when the dog has matured enough to be able to withstand anesthesia and surgical stress.

Animals↗
PubMed1994

Patellofemoral Pain After Total Knee Arthroplasty.

The incidence of patellofemoral complications after total knee arthroplasty has been reported to range from 2% to 7%. Such complications include pain, sub-luxation, dislocation, loosening, and wear. Usually these complications are attrib-utable to prosthetic design or surgical technique. Today, it is understood that patellofemoral prostheses must have a degree of congruence; must allow smooth, not abrupt, motion; and must restore a relatively normal size relationship between the patella and the femur. Surgical technique requires strict attention to (1) restoration of the patellofemoral spacing while avoiding "overstuffing" of the patellofemoral compartment; (2) accurate superior and medial positioning of the patellar component; (3) restoration of the rotational alignment of the femoral and tibial components; and (4) appropriate balancing of the patellofemoral soft tissues.

Journal Article↗
PubMed1982

Surgical treatment of recurrent subluxation of the patella in athletes.

The authors describe the results obtained in fifteen athletes suffering from recurrent monolateral subluxation of the patella by a new technique which should represent a considerable improvement over existing methods, both in surgical and rehabilitation phases. The treatment consists of: a) a surgical stage comprising extensive lateral mobilisation by section of the lateral capsule and the external alar ligament, extensive manual detachment of the vastus lateralis muscle, and osteotomy performed obliquely to the frontal plane with antero-medial transposition of the tibial tuberosity to realign the extensor apparatus; b) a post-operative stage characterised by immediate mobilisation of the knee without the application of a plaster cast. The aim of this method is to eliminate above all the instability caused by recurrent subluxation of the patella, to cancel out any abnormal stress exerted on the femoral condyle by the patella, to normalize the extensor apparatus, to bring about the regression of any incipient chondromalacic lesions, and to prevent femoro-patellar arthrosis by restoring the anatomical and functional equilibrium of the femoro-patellar joint. The clinical and radiographic results determined by follow up examinations performed between one year and two and a half years after the operation were so satisfactory that the authors extended the method to recurrent subluxations in non-athletes.

Adolescent↗
PubMed1994

Reconstruction of extensor mechanism after trauma and infection by transposition of the Achilles tendon: report of technique and four cases.

High-energy injuries to the knee often involve extensive soft tissue loss as well as fractures. In certain situations, the patellar tendon may be lost due to initial injury or post-injury complications such as infection. Use of the gastrocnemius flap is a popular method of covering the defect as well as controlling infection and promoting healing by increasing local vascularity. We present a method of reconstructing the patellar tendon by extending the use of the gastrocnemius flaps using its Achilles tendon and calcaneal insertion. The distal insertion of the Achilles tendon is fixed to the tibial tuberosity with a cancellous screw, and the proximal end is sutured to the quadriceps muscles. The knee is immobilized for 1 week, after which the knee is mobilized in a hinged brace. Three of the four cases had good results, one a moderate result (the initial injury was extensive, with dislocation of the knee).

Achilles Tendon↗
PubMed2003

Patients with lateral tracking patella have better pain relief following CT-guided tuberosity transfer than patients with unstable patella.

In patients with either lateral tracking patella or unstable patella the pathological lateral position of the tuberosity can be corrected by a medial transfer. This study compared the results of subtle CT-guided correction of the tuberosity for objective unstable patella (n=27) with the results for lateral tracking patella (potential instability) as described by Dejour (n=16). Follow-up was 37 months. CT revealed a pathological lateralization of the tibial tuberosity-trochlear groove greater than 15 mm in 41 knees. These patients underwent medialization of the tibial tuberosity up to 10-12 mm lateral from the trochlear groove, and 28 patients underwent a distalization to normalize the Caton index to 1.0-1.2. Results were evaluated using Cox' method. Patients with objective patellar instability were rated as 11% excellent, 52% good, 33% fair, and 4% poor. All patients became stable except one who had a 6 degrees valgus alignment. Although 96% had improved stability, 33% of the patients still had pain. The patients with lateral tracking patella (potential instability) were rated as 37.5% excellent, 44% good, and 19% fair. The lower proportion of pain relief in patients with unstable patella is likely the result of the cartilage damage experienced by these patients following multiple dislocations. Thus the patient with lateral tracking patella without patella dislocations must be differentiated from the one with unstable patella. Their prognosis in pain relief is better.

Cohort Studies↗
PubMed2000

[Osteolysis after total knee prosthesis].

PURPOSE OF THE STUDY: The aim of our work was to study X-rays showing osteolysis after 5 years and more in 122 prosthesis and to try and assess such complication, often described in the United States but seldom in Europ. MATERIAL: We are dealing here with 122 retaining posterior cruciate ligament, mostly cementless prothesis implanted between 1985 and 1992 84 chromium-cobalt prosthesis (PCA and Themis) implanted in 34 males and 88 females with an average age of 67 (45-81), 87,7 p. 100 had femoral cementless components and 70 p. 100 tibial cementless components. METHODS: All patients were examined and had X-rays at an average of 6,9 years. Specially considered were X-rays showing a possible osteolysis. We looked for possible complication (external laxity, anterior femoral dislocation and polyethylene wear), assessment of the mechanical axis and for clinical results (Hungerford score) RESULTS: Revisions: 19 arthroplasties were revised for PE wear tibial loosening metallosis or patella problems The postoperative score according to Hungerford was 84,5 p. 100 for PCA prosthese and 87 p.100 for the Themis. On the X-rays were only few osteolysis to be found: 9 cases (7,3 p. 100). For the PCA series: 3 femoral osteolysis, 1 tibial at 12 years, and one patellar osteolysis. For the Themis series: no femoral osteolysis, 3 tibial and one patellar osteolysis. Osteolysis are apparent on X-rays in profile for the femur and the patella, and in both profile and frontal X-rays for the tibia. Clinicaly 4 osteolysis really asymptomatic were not re-operated. 5 were revised: one 11 years later for femoral and tibial loosening, two for a patellar loosening, the other two patients had to be reoperated on for metallism (titanium's femoral component) and for those two instances osteolysis were discovered during the complication. DISCUSSION: Osteolysis after TKA appears unusual in our experience without bearing on frequency finded by american authors with a lesser follow-up (Engh 11,1 p. 100 after 4,5y, Peters 16 p. 100 after 2,9 y, Robinson 9,18 p. 100 after 4,6 y). American litteratur analysis shows that the important number of osteolysis is due to: - either to dual-metal using (Co-Cr component with Titanium screws for exemple), - or bad quality of polyethylene (compressed), - or a bad design of former prosthesis. CONCLUSION: Interface illness, linked to the production of wear debris, osteolysis after total knee arthroplasty is rarer than after a hip one, probably because size of debris is different, larger in knee than in hip. It is likely that the improvement of PE quality, design of prosthesis, as well as a better knowledge of osteolysis mechanism will allow to delay this complication wich is in a long term ineluctable.

Aged↗
PubMed2006

Patellar luxation in 70 large breed dogs.

OBJECTIVES: To report the signalment, history, clinical features, and outcome in dogs weighing greater than 15 kg, treated surgically and non-surgically for patellar luxation. Risk factors for the development of patellar luxation, postoperative complications, and outcome were evaluated. METHODS: Details regarding signalment, bodyweight, breed, aetiology, unilateral or bilateral luxation, duration of lameness, grade of luxation, direction of luxation, grade of lameness at presentation, concomitant cranial cruciate ligament rupture, method of treatment, surgical technique, surgeon, and complications were obtained from the medical records. Outcome was graded as excellent, good, fair, or poor, according to the degree of lameness. RESULTS: Seventy dogs (45 males and 25 females) were included. Thirty-five had bilateral luxations (105 limbs). Mean age was two years, and mean weight was 30 kg. The relative risk for Labrador retrievers was 3.3 (P<0.001). All luxations were developmental. Luxations were medial in 102 stifles and lateral in three. Fourteen stifles had concomitant cranial cruciate ligament rupture. As the grade of patellar luxation increased, so did the grade of lameness (P<0.001). Surgery was performed in 70 stifles, and outcome was excellent/good in 94 per cent and fair/poor in 6 per cent of stifles. Complications occurred in 29 per cent of stifles, and increasing bodyweight was found to be a risk factor (P=0.03). Thirty-five stifles were managed non-surgically, and outcome was excellent/good in 86 per cent and fair/poor in 14 per cent of stifles. CLINICAL SIGNIFICANCE: In view of the potential risk of postoperative complications, all surgically treated cases of patellar luxation in large breed dogs should be managed with a femoral trochleoplasty, a tibial tuberosity transposition (stabilised with K-wires and a tension band wire), and soft tissue releasing and tightening procedures.

Animals↗