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A case of fracture-dislocations of the hip, knee and tarsometatarsal joints in the same limb is presented. This combination of injuries has not previously been reported. There were no associated neurovascular complications.
There has been only one previous report of dislocation of a posteriorly stabilized total knee arthroplasty. The authors present two further cases of subluxation of this prosthesis and report a method of accomplishing reduction that could not otherwise be achieved by conventional techniques. The current design of this prosthesis enabled revision of the polyethylene tibial component to be undertaken without removal of the cemented metal-backing tray, an advantage not previously appreciated.
BACKGROUND: Diastrophic dysplasia results in severe disproportionate short stature, generalized joint deformities, and early osteoarthritis. The knee joint often has an abnormal valgus position and is unstable, and degeneration of all joint compartments occurs, even during growth. The purpose of our study was to evaluate the clinical and radiographic results of total knee arthroplasty in a series of patients with diastrophic dysplasia. METHODS: Between February 1992 and March 2000, twenty-one primary total knee arthroplasties were performed on fourteen consecutive patients with severe osteoarthritis due to diastrophic dysplasia. The patients were followed prospectively with clinical examinations, determination of the Hungerford knee scores, and radiographs. Preoperatively, ten knees had chronic dislocation of the patella. The mean duration of follow-up was 3.4 years. RESULTS: The mean Hungerford knee pain and total scores improved from 5.8 points and 46 points preoperatively to 50 points and 83 points, respectively, at the final follow-up examination (p < 0.001 for both comparisons). Two knees required a distal femoral corrective osteotomy because of metaphyseal angulation. None of the total knee arthroplasties had to be revised during the follow-up period. Six complications were recorded. CONCLUSIONS: Total knee arthroplasty substantially improved the function of patients with diastrophic dysplasia. Additional peripatellar procedures were commonly needed, and complications were frequent.
Many patients with larsen syndrome have been misdiagnosed as having arthrogryposis. Larsen syndrome should be considered in any child with multiple joint dislocations, particularly when the knees are involved. Spinal malalignment of a serious degree was encountered in five of the six patients we report and appears to have been underemphasized previously. Two of the patients had unusual ossicles of uncertain derivation at the elbow. This has been described only five times before.
Fifty-eight athletically active study participants with 69 knees that had experienced patellar dislocations were available for followup after being selected for a functional rehabilitation program without antecedent immobilization. Follow-up evaluation was at a minimum of 24 months after onset of treatment and averaged 46.2 months. Good or excellent results occurred in 39 (66%) knees treated after an initial patellar dislocation and in 15 (50%) knees with a chronic history of patellar instability. Twenty-six percent of the 69 knees had experienced recurrent patellar instability at followup. Overall, 42 patients (73%) were satisfied with their knees after this nonsurgical management. Anatomic predisposition and onset of bilateral instability at an early age were found to be significant factors associated with a less favorable outcome.
The remnants of the medial patello-femoral ligament (MPFL) of 67 knees, 18 with acute patellar dislocation and 49 with chronic patellar dislocation, were studied. The MPFL injuries of the acute cases were categorised into 2 groups: an avulsion tear type and a substantial tear type. The chronic cases were put into 3 groups: those with loose femoral attachment (9 knees), those with scar tissue formation or abnormal scar branch formation (29 knees), and those with no evidence or continuity of the ligament (absent type) (11 knees). It is concluded that incompetence of the medial patello-femoral ligament is a major factor in the occurrence of recurrent patellar dislocation and/or an unstable patella following an acute patellar dislocation.
BACKGROUND: Recurrent patellar dislocation may be associated with trochlear dysplasia. Trochleaplasty is a surgical procedure which strives to deepen the trochlear groove. We evaluated the clinical and radiological effect of trochleaplasty after a minimum follow-up of 2 years. PATIENTS AND METHODS: We examined 19 knees in 16 patients at a mean of 3 years after trochleaplasty. Postoperatively, a subjective questionnaire, a Kujala score, and tests for potential patellar redislocation and apprehension were evaluated. On radiographs we evaluated the preoperative and postoperative crossing sign, trochlear depth, trochlear bump, and patellar height. On CT scans, the pre- and postoperative tibial tuberosity to trochlear groove distance (TTTG) and the patellar inclination angle were measured. RESULTS: 16 of 19 knees improved subjectively. The Kujala score increased from 56 to 80 points at the latest follow-up. None of the patients sustained a redislocation. 5 patients had medial parapatellar tenderness, including 4 with persistent apprehension. Radiological signs of trochlear dysplasia were corrected. INTERPRETATION: Patellofemoral instability with underlying trochlear dysplasia can be treated successfully by trochleaplasty.
To determine the effectiveness of nonoperative and operative treatment of initial acute patellar dislocation, we reviewed the charts of 399 patients with the diagnosis of an acute dislocation, seen during a 30 year period. One hundred patients (103 knees) met the criteria for inclusion in the study. The average age of the patient at injury was 21.7 years (range, 9 to 72 years). Length of followup averaged 8 years (range, 2 to 26 years). Retrospectively, we divided the patients into two groups, according to the examination of their unaffected knee. Group I (69 knees) showed evidence on examination of congenital abnormality of the extensor mechanism in the unaffected knee, indicating a predisposition to dislocate with less significant trauma. Group II (34 knees) showed no clinically perceptible congenital predisposition to dislocate based on examination of the unaffected knee. In the nonoperatively treated knees in Group I, there was a 52% (28/54) incidence of good or excellent results. The nonoperatively treated knees in Group II had a 75% (15/20) incidence of good or excellent results. Acute dislocation occurred more frequently in males than in females. Recurrence was rarer in patients whose initial dislocation had occurred when they were over 15 years old. Contrary to recently published reports, primary acute traumatic patellar dislocations can be treated with nonoperative therapy with good or excellent results. Initial evaluation should include examination of the uninvolved knee which, if found to have signs of congenital abnormality, would indicate a worse prognosis.
From 1970 to 1978, 29 patients had a unilateral operation for bilateral recurrent dislocation of the patella. We examined 21 of them at a mean of 14 years postoperatively. Eighteen of these patients had evidence of generalised joint laxity. Six of the operated knees and four of the unoperated knees still had recurrent dislocations. The operated knees were clinically worse, with a significantly higher incidence of osteoarthritis. We concluded that the operations used to treat recurrent dislocation of the patella may have had short-term benefits, but did not cure the patients in the long term.
The follow-up of 50 knees treated with the modular Marmor prosthesis and 50 with the Guepar hinge joint included tangential radiography of the femoro-patellar joint. After Marmor arthroplasty lateral patellar dislocation was found in seven knees, in six causing pain. After Guepar arthroplasty lateral patellar dislocation was found in 32 knees, but pain was present in only three. There was only a questionable correlation between pre-existing valgus deformity and postoperative lateral patellar dislocation, and an external rotation deformity of the lower leg was found in only five cases after Guepar arthroplasty. Thus, neither phenomenon could explain the high incidence of lateral patellar dislocation in the Guepar series. These dislocations must be assumed to be due to the unphysiological strain on the extensor apparatus inherent in this type of prosthesis.
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).
The rule of no thumb test was compared with the towel clip test in determining the need for lateral retinacular release in 200 consecutive primary total knee replacements. The towel clip test was positive in 13 knees (6.5%) and the rule of no thumb test was positive in 78 knees (39%). Using a positive towel clip test as the indication for lateral retinacular release, there was no radiographic evidence of patellar tilt, subluxation, or dislocation in any knee at 6 months postoperatively. Therefore, the rule of no thumb test falsely predicted the need for lateral release in 65 knees (32.5%). The authors advocate the towel clip test to determine the need for lateral retinacular release.
The management of patellar dislocation syndrome has traditionally been difficult. There are no golden standard methods for patellar dislocations probably due to the many etiologies. However, it is known that medial patellofemoral ligament (MPFL) is damaged when the patella is dislocated. The purpose of this study is to examine whether our method of MPFL reconstruction is useful for the treatment of dislocated patellae and unstable patellae. Forty-six knees (43 patients) of 68 knees (65 patients) that were operated on using our surgical procedure for MPFL reconstruction with the advancement of the vastus medialis or the MPFL reconstruction with Insall's procedure were followed up for at least 5 years. The patient age ranged from 6 to 43 years. These knees consisted of six habitual dislocation patellae, twenty-six recurrent dislocation patellae, ten traumatic dislocation patellae, and four unstable patellae. The patients were evaluated pre-operatively and more than three times post-operatively at 6, 12, 36, 60, or 120 months. No patient experienced patellar dislocation after surgery. Their post-operative Kujala's scores were significantly improved. On conventional X-ray and on stress X-ray evaluations, the mean values for congruence angle, tilting angle, lateral shift ratio, medial stress shift ratio, and lateral stress shift ratio at the final follow-up (60 or 120 months) were demonstrated to be within the normal range. We conclude that our MPFL reconstruction method with the advancement of the vastus medialis or with Insall's procedure might be recommended for the treatment of habitual, recurrent, and indeed any other type of patellar dislocation, as well as for unstable patellae.
A 12-year-old girl with a history of intrauterine growth delay, hip dysplasia, dislocated elbows and knees, dislocatable knuckles, bifid thumb, joint laxity and short stature is presented. She developed glaucoma at age four and was operated at age 14. Her sister had similar dislocations and died of complications of an atrioventricular canal at age three months. Clinical and genetic features of these two patients are discussed as well as their similarity and differences with the Larsen syndrome.
Dysfunction of the patellofemoral mechanism presents in many ways. Results from different realignment procedures show great variability in patient outcome. A surgical technique is presented that attempts to correct all the abnormalities of patellofemoral maltracking. The procedure consists of a lateral release, a vastus medialis (obliquus) tendon advancement, and a tibial tubercle transfer. Along with being moved medially, the tubercle also is moved distally to correct patella alta and elevated anteriorly to reduce patellofemoral joint reaction forces. One hundred seven knees in 84 patients were reviewed. Fifty-five percent of patients had frank dislocation. The remaining patients had anterior knee pain and had abnormal patella tracking on examination. The mean followup was 5.6 years. Seventy-nine percent of patients had a good to excellent functional outcome and 84% of patients stated they would have the operation again. Two patients with marked generalized ligamentous laxity had recurrent dislocation of the patella.
Eighteen arterial reconstructions after trauma in the region of the knee joint were performed between 1970 and 1976. In seven cases there had been fracture of the distal femur, in five of the head of the tibia, in three dislocation of the knee joint or severe contusion of the popliteal artery. In 12 cases referral had been eight hours or later after injury. The concomitant vessel injury was not recognised in six. Vascular reconstruction by direct suture with a venous patch was performed in eight, interposition of a venous autograft in five, and saphenous vein bypass in four. Results depended upon length of ischaemia time and the level of the vascular injuries. Complete restitution to normal was achieved in only two cases, while in the remaining 12 there were defects of motor and sensory function as seen in the post-ischaemia syndrome. In four cases above-knee amputation was necessary despite successful reconstruction of the artery because there was irreversible ischaemic damage with tissue necrosis. To improve these results careful examination of blood vessels and, in questionable cases, angiography is recommended for every trauma victim.
Before bony maturity, the treatment of the recurrent dislocation of the patella is based on tendinous transfers. These distal procedures were often combined with proximal procedures on the medial or lateral patellar retinaculum and vastus medialis muscle. For the purpose of analysing efficacity of the medial third tendon transfer to the distal and deep part of the medial collateral ligament before the bony maturity, 24 children have been reviewed with a post operative follow up of 14 months to 6 and half years. There were 4 boys and 20 girls between 7 to 15 years old at the time of surgery. The troubles duration before the operation was from a few days to 4 years and the pathology was very often bilateral (40 knees). The recurrent dislocation of the patella was present 6 times, an instability 25 times and a traumatic dislocation 9 times. The technical procedure was every time a stabilisation with the transfer of medial third of the patellar tendon, associated except in 6 cases with a correction of the patellar motion by patellar retinaculum plasties. The functional result has been evaluated according to the sport activity and the ordinary life, with very hard criteria according to patient's age. Twenty-four times the result was excellent (60 per cent), 8 times good (20 per cent) and fair 8 times. Two complications have been observed. The improvement of the trochlea angle, and the trochlea deepness have been significant. Sixteen patients (27 knees) have been reviewed after the bony maturity and no growth disturbance of the tibial tuberosity has been observed.(ABSTRACT TRUNCATED AT 250 WORDS)
The case of a patient aged 73 years who, following an accidental fall on a staircase, suffered an acute intraarticular dislocation in the left knee-cap is presented. This exceptional dislocation presented incarceration of the proximal kneecap pole in the femoral intercondylar groove. A reduction was carried out under general anaesthetic due to pain and muscular contraction in the attempts at reduction without anaesthetic. We made a surgical check that ruled out associated lesions to the extensor apparatus, soft parts, joint structures and osteophytes. The patient presented advanced arthrosis, above all femoral-patellar. Following two weeks of immobilisation, the patient restarted mobility. There has been no relapse or other type of complication.