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In this case report the difficulty of differential diagnosis of the growing skeleton is demonstrated. The ossification of the patella is discussed, and variants of normal ossification are described. Emphasis is given to the necessity of knowledge of anamnesis, kind of accident, clinical aspects, x-ray diagnostic and comparative films.
The presence of the "hot patella" sign was evaluated in a prospective study of 200 consecutive bone scans, and in a review of scans from 148 patients with various metabolic bone disorders and 61 patients with lung carcinoma. The incidence was found to be 31%, 26% and 31% respectively. This sign is an extremely common scan finding and may be seen in association with a wide variety of disorders. It is concluded that this sign cannot be considered to be of diagnostic value.
A case of central (intercondylar) dislocation of the patella is reported. The displacement could be reduced easily. At surgery, the quadriceps tendon was found to be intact.
One hundred seven patients with fractures of the patella were treated by percutaneous suture. The method has the advantage of being simple and relatively nontraumatic. The reduction and the functional recovery were generally excellent. The reduction was poor in five cases, three of which had open reduction and internal fixation. After the percutaneous suture with steel wire is in place, the wire provides sufficient strength for internal fixation. The quadriceps expansion needs no repair. Neither open reduction nor percutaneous suture with cerclage solves the problem of the tendency of the fracture fragments to gap anteriorly. Percutaneous suture without Kirschner-wire internal fixation, with the principle of tension-band wiring, is adequate.
For local operative correction of slipping patella, we recommend a modified plasty of the patellar retinaculum apparatus. This simple operation can even be performed on adolescents with still open epiphyseal cartilages. The technique of our operation is described. The early results during the last 30 months are very good. None of our 20 patients noted a reluxation, and all have resumed their sports.
Results of the conservative and operative therapy in chondropathia patellae are reported. A high percentage of freedom from symptoms was achieved by physiotherapeutic measures and intra-articular Arteparon-injections.
Aneurysmal bone cysts of the patella are extremely rare. Only 4 cases have been reported in the literature. The authors add a fifth case which came under their observation.
Three cases of sleeve fractures of the patella are reported. These lesions are epiphyseal fractures. Attention is drawn to the fact that the diagnosis may be missed. Surgical treatment is necessary to attaining and maintaining reduction. The authors focus on that avascular necrosis is important in sleeve fractures and the open reduction increases this risk.
The authors report 12 cases of osteochondritis dissecans of the patella. The relative rarity of this condition (one hundred published cases) is perhaps only apparent, as the diagnosis is sometimes difficult early in the disease. Drawing from their personal cases and from data in the literature, the authors recall the clinical and radiological signs, describe the place of complementary investigations and therapeutic indications and discuss the various pathogenic theories, none of which are fully satisfactory.
A 50-year-old man with asymptomatic bilateral congenital permanent dislocation of the patella had never been treated until two years following a fall on his left knee, on which occasion he had torn the lateral meniscus. In this unusual case, surgical treatment was performed to restore the power of the active extension in the left knee by removal of the torn meniscus. The results at 28 months following up were satisfactory for normal occupational activities.
Four familiar cases of the Nail-patella syndrome are reported in this article. All the patients displayed clinical and radiographic changes characteristic of this syndrome. All of them had elongated and sharp-pointed postero-inferior iliac prominences. This bony abnormality has not been previously described in this syndrome.
Uncertainty still exists as to the necessity to resurface the patella in total knee arthroplasty. In a series of 77 ICLH knee arthroplasties there were 12 bilateral cases which had a prior patellar resurfacing on one side and a patelloplasty on the other. The results of those who had a patellar resurfacing were slightly better, but only three patients could tell the difference in their knees. Incidence of patellar fracture following resurfacing was much higher than that following patelloplasty.
Using anatomical specimens for experimental investigations, the physical-technical prerequisites for proper demonstration of the femoro-patellar articulation were determined and the following results obtained: hyaline cartilage possesses an attenuation value of 25-35 HU; artificial lesions from 1 mm. deep and 2 mm. wide minimum can be visualized; the use of positive contrast medium is best suited for demonstration of chondral lesions. In clinical practice we found that the various stages of cartilaginous degeneration peculiar to chondromalacia (Fründ I to III) are clearly demonstrated by CT arthrography. In CT the predisposing changes in the morphology of the patella and the femoro-patellar articulation are more precisely defined than in conventional tangential roentgenograms. In 69 cases the CT arthrographic findings could be verified at operation. However, the extent and severity of the lesions was, at times, underestimated.
Using a new method for measuring the distal femoral torsion (Janssen a. Prüssner 1977) it is possible to determine the encreased medial torsion of the distal femur in most of the patients with dislocation of the patella. A group of patients with dislocated knee-cap was studied for this purpose. The characteristic clinical and x-ray features are listed and weighted according to their value. They throw a new light on the pathogenesis and pathomechanics of patellar luxation, and point to the need to reclassify the different types of luxations according to etiological aspects.
When chondromalacia patellae is caused by lateral capsular and retinacular tightness, subcutaneous lateral release affords relief of pain. The operation, performed at the time of arthroscopy, causes minimal morbidity, and it is advantageous when cosmetics are of concern. Range-of-motion exercises are begun on the second postoperative day to keep the retinaculum open. In the postoperative examination of 25 knees at 24 to 45 months in 15 patients, there were 20 excellent and five good results; none was made worse. There were two postoperative hemarthroses. The procedure is most effective in the carefully selected patient with demonstrable tightness of the lateral capsule and retinaculum. Abnormal attachments of the iliotibial band and synovial plicae are also significant in the etiology of this syndrome.
Dysplasia epiphysealis hemimelica of the patella seems not to have been previously reported. The condition appeared in a five-year-old boy and treatment was excision of the lesion.
Chondromalacia patellae is a pathologic diagnosis. The initial diagnosis is patellofemoral pain syndrome, unless actual evidence of chondromalacia is available. The success of a nonoperative treatment program is correlated with improvement of thigh musculature balance. An arduous muscle-strengthening program is part of the treatment protocol. Only eight in a series of 100 patients required surgery. The physician's attitude and the patient's confidence are important elements in the success rate.
This case report describes a horizontal intra-articular dislocation of the right patella in a 57-year-old male. This is an extremely rare injury. Our case is unusual in that previous authors have described this injury as exclusive to adolescents. A mechanism has been suggested for the causation of this injury. Our case does not seem to conform to the mechanism described, in that the patient's knee was locked in extension, not flexion, at the time of injury.