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We report the case of a six-year-old boy with Down syndrome who presented with flexion contractures of both knees and genu valgum. The diagnosis of bilateral congenital dislocation of the patella was established by clinical and xray examination. The patient was treated surgically with a satisfactory result.
Traumatic anterolateral dislocation of the fibular head is an uncommon sports injury which is easily overlooked. Seventeen cases have been collected during private practice over the years. The typical mechanism of injury is a fall on the affected flexed knee with the leg adducted under the body and the ankle inverted. On physical examination there is an obvious bony prominence laterally of the fibular head and varying disability with activities; there is no significant effusion or signs of internal knee derangement or instability. Comparison identical radiographic views are necessary to confirm the diagnosis: on the anteroposterior view the fibular head is displaced laterally and the proximal interosseous space is widened; on the lateral view there is a greater overlap of the fibula on the tibia on the affected side. Peroneal nerve and ankle injuries can occur concomitantly with anterolateral proximal tibiofibular dislocation. Treatment options are closed or open reduction acutely and local strapping or fibular head resection for chronic cases based upon time of presentation and disability.
Proximal tibiofibular joint dislocation is an uncommon injury, which may be easily missed on plain radiography. If recognised, it can be treated in the emergency department, avoiding surgery and long term problems. The case is presented of a 22 year old male rugby player who was tackled from the left hand side while turning to the left. He heard a "pop" from his knee as he fell to the ground. Clinical examination revealed a prominence in the area of the fibular head. There was no evidence of peroneal nerve injury. Plain x rays confirmed a clinical suspicion for anterior dislocation of the proximal tibiofibular joint. Proximal tibiofibular joint dislocation typically occurs when the knee is slightly flexed and the foot is rotated and plantar flexed. Antero lateral dislocation is the most common pattern. Diagnosis is largely clinical, but the findings may be subtle. Plain films may not show any abnormality and computed tomography is the investigation of choice if there is clinical suspicion for the injury. The dislocation should be reduced in the emergency department, but controversy exists whether early mobilisation or casting is the most appropriate course of action.
We have reviewed 85 knees in 71 patients after total-condylar posteriorly stabilised (Insall-Burstein) knee replacement with an average follow-up of five years. Excellent or good results were obtained in 90% with an average maximum flexion of 98 degrees. The four poor results (5%) included two with deep infection, one with patellar dislocation and one with loosening. Four other knees (5%) showed signs of probable tibial loosening, but the patients were asymptomatic, the clinical results had not deteriorated with time and lucent lines had not progressed. Varus alignment of the knee and a varus tilt of more than 2 degrees of the tibial component correlated with the incidence of lucent lines around the tibial implant. No patellar stress fractures were seen but impingement symptoms were present in 20%, although they were troublesome in less than half of them. The virtue of the prosthesis lies in its versatility for use in the severely deformed joint.
Normal metaphyses in infants contain a step-off not to be confused with child abuse. Extension of physeal lucency into the metaphyses can be a sign of healing child-abuse fracture of experimental physeal fracture, as well as deferoxamine overdose. Sonography can reveal costochondral dislocation, the pattern of healing fracture callus, the patellar tendon in jumper's knee, synovium of rheumatoid arthritis, sequestrum in advanced osteomyelitis, the unossified dislocated patella, and, even after 2 years of age, the dislocated femoral head. Further developments concern bone scanning, MR imaging, CT, and plain films of specific trauma, tumor, and infectious, metabolic, and orthopaedic conditions. Ultrasound has been proven useful for radiologist removal of soft tissue foreign bodies, whereas CT can be helpful for osteoid osteoma nidus removal under imaging control.
Recurrent dislocation of the patella is a disorder with a complex aetiology. Several surgical procedures have been recommended for its correction, but there are few clinical or radiological guidelines to facilitate the selection of a particular procedure. The results of treating a series of 29 knees are presented with a follow-up of at least 2 years. A significant correlation has been found between the horizontal movement of the centre of the patella on quadriceps contraction (quadriceps pull test) and surgical outcome when lateral release alone is selected for the correction of recurrent patellar dislocation.
A detailed examination was undertaken of hospitalized car occupants who sustained a lower limb injury in a frontal crash. The assessment included an analysis of the type, severity and causes of these injuries and mechanisms involved in lower limb fractures. The findings showed that fractures and dislocations occurred in 88% of lower limb injury cases, that more than half were from crashes < 48 km hour-1 and that the number of fractures was directly proportional with delta V. Ankle dislocations and foot fractures from the floor and toe pand were the most common injury-source combination overall. The most frequent mechanisms of lower limb fracture were compression, perpendicular loading of the knee and crushing or twisting of the foot. The study points to the need for further regulation to reduce lower limb fractures in frontal crashes and highlights a number of possible countermeasures.
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Three patients with short stature, joint laxity, and peculiar pelvic radiology are described. The first case is similar to those described by Desbuquois et al., with deviation of digitis and supernumerary metacarpal bones. The other two children are less severely affected and are compared with others reported in literature. The authors suggest the homogeneity of the Desbuquois syndrome in spite of the variability of expression.
We describe a modification of the Elmslie-Trillat operation which includes a lateral retinacular release and medial realignment of the tibial tuberosity, but omits medial capsulorraphy. Seventy-five patients were reviewed with a follow up longer than 2 years and the results compared with the conventional Elmslie-Trillat procedure, which consists of lateral release, medial realignment of the tuberosity and medial capsulorraphy. The simpler operation can work as well and the period of rehabilitation is shorter. The incidence of injury to the saphenous nerve is reduced and the cosmetic appearance is more satisfactory. We conclude that medial capsulorraphy is usually unnecessary in this type of procedure.
Joint motion was measured for the intact and cranial cruciate ligament (CCL)-deficient stifle in five large dogs using an instrumental spatial linkage and radiophotogrammetry. The linkage was directly attached to the bones using modified bone plates. Motion data were presented in terms of a clinical coordinate system. Stifle kinematics were highly reproducible for a given dog. For intact stifle kinematics, the swing phase included flexion-extension, internal-external rotation and abduction-adduction, while stance-phase kinematics included only flexion-extension. Loss of the CCL altered joint kinematics over the entire gait cycle. At the swing-stance transition, the CCL-deficient stifle demonstrated an abrupt cranial subluxation of the tibia which was sustained throughout stance. At the beginning of the swing phase the CCL-deficient joint returned to the cranial-caudal alignment seen in the intact joint. The dog's stifle was shown to be CCL-dependent during stance. The dog compensated for CCL loss by reducing the external limb load and by carrying the limb in greater flexion throughout the gait cycle, but was unable to prevent joint subluxation during stance. Stifle kinematics are greatly altered following CCL loss. It is the repetitive, mechanical, dynamic subluxation in a CCL-deficient joint which may be the cause of joint degeneration.
Chronic patellar subluxation is one of the many causes of anterior knee pain. Nonoperative management of this disorder is successful in many patients, but surgical intervention may be necessary for refractory cases. We present a surgical technique for chronic patellar subluxation that is minimally invasive and is focused specifically on the medial patellofemoral ligament.
Sports-related fractures of the knee, although uncommon, do occur during athletic participation. The assessment and management of each fracture type have been emphasized in this article to provide a guideline for treating these acute knee injuries to a successful return to sports-specific competition. Anatomic fracture reduction is necessary to have optimal joint function in the knee as well as stability of fracture for early joint motion, promote bone healing, and avoid traumatic arthritis. This is especially crucial to the injured athlete, as residual deficits of the knee can greatly affect performance. Selection of low-profile implants at the time of surgery to prevent soft tissue irritation and possible implant removal must also be considered with the return to athletic activity.
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Lateral patellar maltracking, subluxation, and dislocation could arguably be grouped together as varying degrees of lateral patellar instability. Besides common anatomical etiological factors, such as genu valgum, patella alta, tibial rotation, and others, the author has found that many of these patients exhibit patellar hypermobility, a seldom mentioned physical finding. Lateral retinacular release fails to address the hypermobility, whereas traditional, more extensive open operations often carry significant postoperative morbidity and disability. This article suggests a surgical approach that combines open medial tethering of the patellar tendon with arthroscopic lateral release. The procedure addresses both etiological factors of anatomical peculiarity and patellar hypermobility, with a relatively benign postoperative course. In a series of 29 cases with follow-up of 4-8 years, results appear encouraging so far.
Unilateral fibula head dislocation is an uncommon injury. Ogden in 1974 reviewed the literature and detected 108 cases [J. Bone Joint Surg. 56(A) (1974) 145-154]. There since have been few reported cases. Bilateral fibula head dislocation only has been reported once [Rheumatol. Int. 5(1) (1984) 45-47]. We report a patient who had developed bilateral fibula head dislocations, each side independently over a 5-year period. We emphasise the rarity of the injury, the necessity of prompt recognition and reduction, and the uncertainty for best management of this injury.
The authors present a new fully arthroscopic technique for the treatment of patellofemoral instability consisting of plication of the medial patellar retinaculum and release of the lateral patellar retinaculum. The indication for this procedure is not only acute patellar luxation, but also recurrent patellar luxation and subluxation. The procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years. The indication for surgical arthroscopic treatment was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. Postoperative results after follow-up of 12 to 26 months have been good with no recurrence of subluxation or luxation. This procedure is a valuable technique for treating patellar maltracking and instability and acute and recurrent patellar luxation, particularly in adolescents and young adults.
This study evaluates the technical results and outcomes of total knee replacement (TKR) in a group of patients with isolated patellofemoral disease based on the amount of bone loss and patella subluxation seen at the time of surgery. Thirty-three TKRs in 25 patients comprised the study group. All patients had radiographic evidence of isolated end-stage disease in the patellofemoral joint and had cemented tri-compartmental knee replacements. All patellae could be resurfaced. Average follow-up was 5.2 years (range: 3.8-8.4 years). Average Knee Society Scores was 62 preoperatively and 96 at final follow-up. There was no correlation in outcomes related to either the amount of patellar wear, size of the patella, or amount of subluxation of the patella. Total knee replacement is an effective means of managing end-stage arthritis of the patellofemoral joint.