Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).Table 1Errors and complications in the treatment of quadriceps and patellar tendon tearsError/complicationClinical effectPreventionDetectionRemedyJudgment errors Missed diagnosis: patella tendon tearPatient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Infrapatellar pain Infrapatellar gap Inability to maintain full active extension Unable to perform straight leg raise Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (alta)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: quadriceps tendon tearVery common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Suprapatellar pain Suprapatellar gapInability to maintain full active extension Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (baja)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: intact retinaculum but torn quadriceps tendonPatient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries(1) Careful physical examination: check for extensor lag(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI(1) Palpable defect in soft tissues proximal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruptionWith severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability(1) Careful review of imaging, particularly sagittal views(2) Thorough physical examination(1) Palpable defect in soft tissues proximal/distal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging Delayed diagnosis: delayed surgeryOperating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeriesPerforming surgery as soon as possible, preferably within first weekProper detection and early management; if noted too late, consider V-Y or Scuderi technique Incorrect diagnosis: partial tendon tearTendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate (1) MRI(2) Ultrasound(3) Physical examination(1) Patient should be able to maintain full active extension(2) Radiographs: normal patellar heightThis individual can be treated nonoperatively with immobilization until the tendon has healed Incorrect diagnosis: retinaculum torn, but quadriceps tendon intactAs long as the tendon is intact, the retinaculum should heal nonoperatively(1) Careful physical examination(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI or ultrasound Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intactMultiple reasons:(1) Femoral nerve palsy(2) Pain(3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc)(1) Thorough history and careful physical examination(2) Additional imaging: MRIConsider aspiration/injection of local anesthetic and reexaminationPotential judgment errors Performing definitive surgery in open injuryConsider staged procedure if contaminated wound(1) Irrigation and debridement(2) Definitive fixationThorough history and careful physical examinationSingle stage management of contaminated or chronically open injuries potentially leads to infection and repair failure Failure to account for diabetesPoor tissue quality that should be accounted for. Delayed wound and tendon healingThorough history and careful physical examination. Tight perioperative glycemic controlLaboratory studies. Patient’s glycemic historyConsultation with patient’s primary care provider/internal medicineAdequate diseased tendon debridement.Delayed postoperative motion to account for expected delayed healingTechnical errors Positioning and preparing(1) Supine, bump under ipsilateral hip to internally rotate lower extremity(2) Consider full muscle paralysis to aid in reduction Inadequate exposureGenerous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella) Failure to identify correct injury pattern: patellar tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from inferior pole patella(2) Midsubstance rupture(3) Distal avulsion from tibial tubercle(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate fixation method Failure to identify correct injury pattern: quadriceps tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from superior pole patella(2) Midsubstance rupture(3) Mixed(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate preoperative planning and fixation method Failure to débride patella/quadriceps tendon stumpFailure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weaknessRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Failure to débride/prepare patella bone bedFailure to débride patella bone bed may predispose to poor healingRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Tendon repair: inadequate tissue for repair of midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsConsider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)? Tendon repair: appropriate tension for midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsLateral radiograph of contralateral leg can help determine appropriate tension Transosseous tendon repair: divergent tunnelsDivergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking(1) Adequate exposure of entire patella(2) Parallel pin drill guide(3) Consider use of fluoroscopy Transosseous tendon repair: tunnel penetration into articular surfaceIatrogenic articular cartilage injury(1) Adequate exposure of entire patella(2) Parallel pin drill guide Transosseous tendon repair: drill breakageBroken drill bit in tunnel(1) Careful drilling technique(2) Do not attempt to change direction of drill hole once started drilling(3) Do not torque drill(4) Use stout drill bit Transosseous tendon repair: anterior placement of tunnelsMay lead to downward tilting of the patella and increase patellofemoral contact forces and pain(1) Place drill holes in center of patella (with respect to AP)(2) If have to cheat, cheat toward articular surface Transosseous tendon repair: overtightening repairMay lead to patella alta or baja(1) Prepare opposite leg to assist with tensioning(2) Obtain intraoperative radiograph and compare with contralateral side Transosseous tendon repair: undertightening repair(1) May lead to patella alta or baja(2) Poor tendon to bone contact may interfere with healing(1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough(2) Adequate retinacular repair Transosseous tendon repair: prominent proximal suture knotsMay lead to skin irritationAttempt to bury knots and cover with surrounding soft tissue Suture anchor tendon repairAdvantages:(1) Less dissection(2) Decreased surgical time(3) More accurate suture placement(4) Low profile Suture anchor tendon repair: anchor pulloutCauses:(1) Poorly placed anchors(2) Poor bone quality(3) Weak anchors(1) Anchors should be placed in center of patella (2) Not to be used in osteoporotic bone(3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels)  Suture anchor tendon repair: proud anchorsProud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healingAnchors should be slightly countersunk to pull tendon firmly into bone trough in patella Failure to repair retinacular tissueMay lead to increased stress on central repair(1) Adequate exposure(2) Suture medial and lateral retinaculumAdditional complications Infection(1) Open injury(2) Comorbidities Diabetes Smoking Chronic disease(1) Irrigation and debridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Wound complications(1) Open injury(2) Comorbidities Diabetes Smoking Chronic disease(3) Prominent sutures(1) Irrigation and débridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Nerve injuryExtremely rareRehabilitation complications Prolonged immobilizationLeads to stiffness and decreased ROMIntraoperative assessment of maximum flexion before gapping between bone and tendon is observedEarly ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively Inadequate immobilization(1) Wound complications(2) Failure of repairROM bracing locked in extension Overly aggressive physical therapyNeed time for tendon-to-bone healing to occurNo forced flexion or active extension in first 6 weeks
In anterior cruciate ligament (ACL) injury, conventional adult reconstruction techniques have to face the potential risk of growth disturbance or angular deformities in skeletally immature patients. The aim of this study was to evaluate the clinical outcomes of ACL reconstruction by conventional transphyseal tunnel technique.
Materials and Methods
On a retrospective basis, we reviewed 25 skeletally immature patients; all the patients showed skeletal maturity at last follow-up, and the mean age was 16.4 years. The average injury to surgery interval was 12.6 months. Clinical outcomes were assessed at a mean of 74.4 months postoperatively using the Lysholm Knee Scoring Scale, the Tegner activity level, the International Knee Documentation Committee (IKDC), and plain radiographs.
All the patients had undergone transphyseal reconstruction of ACL. The mean Lysholm score was 48.36 points preoperatively and 93.32 points postoperatively; the mean Tegner activity level was changed from 3.0 points to 5.6 points. The mean IKDC level was categorized as C preoperatively and changed to A postoperatively.
Our midterm outcome at an average 6 years after surgery was satisfactory without significant leg length discrepancies or abnormal alignment of the knee joint. Transphyseal reconstruction of ACL is a good treatment modality in the skeletally immature patient.
Anterior cruciate ligament; Skeletally immature; Adolescent
To evaluate the clinical and functional results of a surgical treatment of patellar dislocation whose etiology was iatrogenic quadriceps fibrosis in children.
Materials and methods
A prospective study was undertaken from February 2004 to December 2009. The study included 54 pediatric patients (56 knees) that had developed dislocation of the patella after repeated intramuscular injections of antibiotic(s) into the quadriceps muscle. There were 11 males (20.4 %) and 43 females (79.6 %). The patients’ mean age at surgery was 7 years, 9 months (range 6 years, 4 months to 12 years, 6 months). A complete history of each patient was recorded. The affected knees were evaluated preoperatively and postoperatively on the basis of the symptoms, signs, and roentgenographic findings. Patellar dislocation was classified according Bensahel’s criteria. All patients had a three-part surgical procedure that combined capsulorrhaphy, quadricepsplasty, and transfer of the vastus medialis oblique to the superior border of the patella.
There has been no poor postsurgical result or recurrence so far; we have noted an ugly scar in nine knees (16.1 %), limitation of the knee flexion in five knees (8.9 %), and loss of extension of 5 °–20 ° in four knees (7.1 %). Overall, we attained excellent results in 39 knees (69.7 %), good results in 13 knees (23.2 %), and fair results in four knees (7.1 %).
In our cases of pediatric dislocation of the patella caused by iatrogenic quadriceps fibrosis, the introduced three-part surgical procedure has shown great success in restoring the realignment mechanism of the patella. The technique is simple, safe, and effective in skeletally immature children.
Patellar instability; Patellar dislocation; Iatrogenic quadriceps fibrosis; Surgical treatment; Quadricepsplasty; Capsulorrhaphy; Subluxation of the patella; Developmental dysplasia of the patella (DDP); Malformative dislocation
Medial patellofemoral ligament (MPFL) reconstruction has become an accepted technique to treat patellofemoral instability, and numerous surgical techniques have been described to reconstruct the MPFL. We describe a MPFL reconstruction procedure where bone-fascia tunnel fixation occurs at the medial margin of the patella for recurrent patellar dislocation.
MPFL reconstruction is the preferred operative treatment for recurrent patellar dislocation. The purpose of this study was to report a simple technique for reconstruction of medial patellofemoral ligament with bone-fascia tunnel fixation at the medial margin of the patella for recurrent patellar dislocation and to evaluate the results at 6-year-minimum follow-up.
The study included 65 patients (28 males, 37 females; mean age, 29.4 ± 5.6 years) who underwent MPFL reconstruction using the bone-fascia tunnel fixation at the medial margin of the patella technique and who were followed for a mean duration of 78.5 ± 3.8 months. Objective assessment, Kujala scale, Lysholm score, and Tegner activity score were obtained preoperatively and at the time of final follow-up.
There were no patellar complications, including redislocation, in the present study. The congruence angle had significant improvement from 19.2° ± 6.3° before surgery to −6.03° ± 0.50° at the last follow-up. The lateral patellar angle had significant improvement from −6.9° ± 3.5° before surgery to 5.1° ± 2.4° at the last follow-up. The patellar tilt angle had significant improvement from 24.5° ± 5.2° before surgery to 12.30° ± 1.90° at the last follow-up. The Kujala score was significantly increased from 52.9 ± 3.2 points preoperatively to 90.1 ± 5.8 points postoperatively (P < 0.05). The mean Lysholm score was significantly increased from 47.2 ± 5.2 to 92.5 ± 6.2 points postoperatively (P < 0.05). The Tegner activity score improved overall from 3.1 ± 0.6 points to 5.8 ± 0.9 points at follow-up.
We have done a simple technique where the MPFL is reconstructed safely to avoid patella fracture, anatomically to restore physiological kinematics and stability, and economically to reduce costs with bone-fascia tunnel fixation at the medial margin of the patella.
Patella; Instability; Medial patellofemoral ligament; Reconstruction; Fixation
Congenital dislocation of the patella is permanent and manually irreducible, and it manifests immediately after birth with flexion contracture of the knee, genu valgus, external tibial torsion and foot deformity. We retrospectively reviewed the results of operative treatment of seven knees in six patients with congenital dislocation of the patella.
The age of the six patients at diagnosis ranged from 8 days to 3.6 years, with an average of 1.3 years, and their age at the time of operation ranged from 0.6 to 3.9 years, with an average of 2.1 years. Serial casting and/or a brace was attempted before surgery in five of seven knees, leading to improvement in the flexion contracture of the knee. All knees were treated operatively in combination with lateral release, medial plication, V-Y lengthening of the quadriceps, medial transfer of the lateral patellar tendon and posterior release of the knee.
Although these deformities were noticed at birth in all seven knees, diagnosis was delayed in three knees due to the low suspicion of the disease and invisible patellae on radiographs. Ultrasonography confirmed the diagnosis of dislocation. The patella was centered in the groove of the femoral condyle after surgery in all knees, but subluxation of the knee with flexion was observed in one knee in which the operation was performed at 3.9 years. Genu valgus and external tibial torsion improved after surgery in all knees. The operated knee was mobile in all cases, with less than 10° flexion contracture of the knee. Flexion contracture did not increase in any of the knees.
Congenital dislocation of the patella should be suspected in every patient with knee flexion contracture, genu valgus, external tibial torsion, foot deformity and delayed walking. Successful results were obtained when the operation was performed in younger children. Other procedures, such as the semitendinosus tenodesis or tendon transfer, might have to be combined to achieve better stability with flexion in older children.
Congenital dislocation; Patella; Quadriceps malrotation; Operative treatment
Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.
Materials and Methods:
Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.
The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.
MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.
Hamstring tendon; medial patellofemoral ligament; patellofemoral instability
The genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.
A retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps:
Complete proximal to distal surgical decompression of the peroneal nerveRadical release and mobilization of the severe quadriceps contracture and iliotibial band contractureDistal lateral hamstring lengthening/tenotomy and lateral collateral ligament releaseProximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocationProximal tibial varus osteotomy with partial fibulectomy and anterior compartment releaseOccasionally, distal femoral osteotomy
In all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.
The operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.
Level of evidence
Chondroectodermal dysplasia; Ellis-van Creveld syndrome; Genu valgum deformity surgery
Recurrent dislocation of the patella is a common orthopaedic problem which occurs in about 44% of cases after first-time dislocation. In most cases of first-time patellar dislocation, the medial patellofemoral ligament (MPFL) becomes damaged. Between 2010 and 2012, 33 children and adolescents (39 knees) with recurrent patellar dislocation were treated with MPFL reconstruction using the adductor magnus tendon. The aim of our study is to assess the effectiveness of this surgical procedure. The outcomes were evaluated functionally (Lysholm knee scale, the Kujala Anterior Knee Pain Scale, and isokinetic examination) and radiographically (Caton index, sulcus angle, congruence angle, and patellofemoral angle). Four patients demonstrated redislocation with MPFL graft failure, despite the fact that patellar tracking was found to be normal before the injury, and the patients had not reported any symptoms. Statistically significant improvements in Lysholm and Kujala scales, in patellofemoral and congruence angle, were seen (P < 0.001). A statistically significant improvement in the peak torque of the quadriceps muscle and flexor was observed for 60°/sec and 180°/sec angular velocities (P = 0.01). Our results confirm the efficacy of MPFL reconstruction using the adductor magnus tendon in children and adolescents with recurrent patellar dislocation.
Acute patellar dislocation or subluxation is a common cause for knee injuries in the United States and accounts for 2% to 3% of all injuries. Up to 49% of patients will have recurrent subluxations or dislocations. Importance of both soft tissue (predominantly, the medial patellofemoral ligament, MPFL, which is responsible for 60% of the resistance to lateral dislocation) and bony constraint of femoral trochlea in preventing subluxation and dislocation is well documented. Acute patella dislocation will require closed reduction and management typically consist of conservative or surgical treatment depending on the symptoms and recurrence of instability. Most patients are diagnosed and treated in a timely manner. We present a 15 years old male with a missed traumatic lateral patella dislocation during childhood. The patient presented as an adolescent with a chronically fixed lateral patella dislocation and was management with surgery. The key steps in the surgical reconstruction of this patient required first mobilizing the patella with a lateral retinacular release and V-Y lengthening of the shortened or contracted quadriceps tendon. Then a combination of MPFL reconstruction using the semitendinosis autograft, tibial tubercle osteotomy with anterio-medialization, and lateral facetectomy was performed. At the one-year follow-up, our patient had improved knee range of motion and decrease in pain. Chronically fixed lateral dislocated patella is a rare and complex problem to manage in older patients that will require a thorough work-up and appropriate surgical planning along with reconstruction.
pediatric orthopedics; patella dislocation; Faulkerson procedure; MPFL reconstruction
The purpose of our study was to analyze the clinical and radiological long-term outcomes of surgically treated traumatic knee dislocations and determine prognostic factors for outcome.
Retrospective consecutive series of patients treated surgically for traumatic knee dislocation with reconstruction/refixation of the anterior (ACL) and posterior cruciate ligaments (PCL) and primary complete repair of collaterals and posteromedial and posteromedial corner structures. 68 patients were evaluated clinically (IKDC score, SF36 health survey, Lysholm score, Knee Society score, Tegner score, visual analogue scale - VAS pain and satisfaction, Cooper test) and radiologically (weight bearing and stress radiographs) with a mean follow up of 12 ± 8 years. Instrumented anterior-posterior translation was measured (Rolimeter, KT-1000). Pearson correlation and stepwise regression analysis was used.
82% of patients (n = 56) returned to their previous work. At final follow-up 6 patients (9%) suffered from pain VAS > 3. The mean side-to-side difference of anterior/posterior translation (KT-1000, 134N) was 1.6 ± 1.6 mm and 2.6 ± 1.4 mm. Valgus and varus stress testing in 30° flexion was <3 mm (normal) in 57 patients (86%). The IKDC score was normal/nearly normal in 38 (58%) patients and the mean Lysholm score 83 ± 17 (intact 98 ± 7). The median Tegner score decreased from 7 preinjury (range 3-10) to 5 at follow-up (range 0-10). The mean Knee Society score was 187 ± 15 (out of maximum 200). In 7 patients (10%) a secondary ligament reconstruction was performed. Three patients (4%) underwent a high tibial osteotomy and four (6%) received a primary unconstrained total knee replacement. According to the Kellgren Lawrence osteoarthritis score only mild degenerative changes were present. The stress radiographs showed stable results for anteroposterior translation. Injury of the lateral collateral ligament, refixation of the ACL/PCL and delayed surgery >40 days were significantly associated with worse outcome (p < 0.05).
Early complete reconstruction can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity. Negative predictive factors for outcome were injury pattern, type of surgical procedure and timing of surgery.
Background and purpose Several mechanisms are responsible for patellar dislocation. We investigated how the primary pathomechanism relates to patient characteristics and the outcome.
Methods 126 patients (81 females) with primary patellar dislocation reported the knee position before the episode, the movement during it, and whether the patella was locked in dislocation. The median age was 20 (9–47) years. The subjective outcome and Kujala, Hughston VAS, and Tegner scores were evaluated after an average of 7 years.
Results 102 patients moved to flexion during the dislocation, 98 from a straight start and 4 from a well-bent start. 10 extended the knee from a well-bent start; they were older (mean 25 vs. 19 years) and more often had low trauma energy (5/10 vs. 15/102) and a locked dislocation (10/10 vs. 50/102). 4 had a direct hit to the knee and 1 only rotated it while stretching. 24 of 60 patients with open growth line of the tibial tubercle and 43 of 66 with closed tubercle had locked primary dislocation (p = 0.005). 33% of girls, 52% of boys, 57% of women, and 71% of men had locked primary dislocation. There was no correlation between trauma mechanism and outcome.
Interpretation Movement to flexion occurred in 84% of primary patellar dislocations and movement to extension in 8%. Spontaneous patellar relocation is common in skeletally immature girls and locked dislocation is common in skeletally mature men.
The management of severe patellofemoral arthritis in young patients remains a significant problem. For many, patellofemoral replacement is not a desirable option. Current surgical techniques for patellectomy disrupt the extensor lever arm causing weakness. We describe a new technique that maintains the extensor mechanism tension and a case series showing good results for patella-only arthritis at a mean follow-up of 11 years.
Eight patellectomies were performed using a new surgical technique in patients with a mean age of 38 years, and an average follow-up of 11 years (range 8–16 years). Patients were followed up using a pain visual analogue scale, Lysholm knee score and patient-reported outcome measures.
All patients experienced pain relief following surgery. Those with patella-only arthritis had better outcomes than patients who had patella and trochlea disease. All patients had either full or near full extension. Lysholm scores were better in patients who had disease confined to the patella.
We believe patellectomy with this tension-preserving technique has a role for the management of anterior knee pain secondary to severe patella-only arthritis in young patients where arthroplasty is not desirable.
Patella; Osteoarthritis; Patellectomy; Anterior; Knee; Pain; Extensor
to evaluate a series of skeletally immature patients who underwent three surgical techniques for anterior cruciate ligament (ACL) reconstruction according to each patient's growth potential.
a series of 23 skeletally immature patients who underwent ACL reconstruction surgery at ages ranging from 7 to 15 years was evaluated prospectively. The surgical technique was individualized according to the Tanner sexual maturity score. The surgical techniques used were transphyseal reconstruction, partial transphyseal reconstruction and extraphyseal reconstruction. Four patients underwent the extraphyseal technique, seven the partial transphyseal technique and twelve the full transphyseal technique, on the ACL. The postoperative evaluation was based on the Lysholm score, clinical analysis on the knee and the presence of angular deformity or dysmetria of the lower limb.
the mean Lysholm score was 96.34 (±2.53). None of the patients presented differences in length and/or clinical or radiographic misalignment abnormality of the lower limbs.
ACL reconstruction using flexor tendon grafts in skeletally immature patients provided satisfactory functional results. Use of individualized surgical techniques according to growth potential did not give rise to physeal lesions capable of causing length discrepancies or misalignments of the lower limbs, even in patients with high growth potential.
Reconstruction; Anterior cruciate ligament; Orthopedic procedures; Reconstrução; Ligamento cruzado anterior; Procedimentos ortopédicos
If anterior cruciate ligament (ACL) reconstruction is to be performed, decision regarding graft choice and its fixation remains one of the most controversial. Multiple techniques for ACL reconstruction are available. To avoid disadvantages related to fixation devices, a hardware-free, press-fit ACL reconstruction technique was developed.
The aim of this study was to evaluate clinical outcome and osteoarthritis progression in long term after ACL reconstruction with central third patellar-tendon autograft fixed to femur by press-fit technique.
Fifty two patients met inclusion/excusion criteria for this study. The patients were assessed preoperatively and at 15 years after surgery with International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, Tegner activity scale and radiographs.
Good overall clinical outcomes and self-reported assessments were documented, and remained good at 15 years. The mean Lysholm and Tegner scores improved from 59.7 ± 18.5 and 4.2 ± 1.0 preoperatively to 86.4 ± 5.6 (p = 0.004) and 6.9 ± 1.4 (p = 0.005) respectively at follow-up. The IKDC subjective score improved from 60.1 ± 9.2 to 80.2 ± 8.1 (p = 0.003).
According to IKDC objective score, 75% of patients had normal or nearly normal knee joints at follow-up. Grade 0 or 1 results were seen in 85% of patients on laxity testing. Degenerative changes were found in 67% of patients. There was no correlation between arthritic changes and stability of knee and subjective evaluation (p > 0.05).
ACL reconstruction with patellar tendon autograft fixed to femur with press-fit technique allows to achieve good self-reported assessments and clinical ligament evaluation up to 15 years. Advantages of the bone-patellar-tendon-bone (BPTB) press-fit fixation include unlimited bone-to-bone healing, cost effectiveness, avoidance of disadvantages associated with hardware, and ease for revision surgery. BPTB femoral press-fit fixation technique can be safely applied in clinical practice and enables patients to return to preinjury activities including high-risk sports.
Habitual dislocation of patella is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee.
It is also termed as obligatory dislocation as the patella dislocates completely with each flexion and extension cycle of the knee and the patient has no control over the patella dislocating as he or she moves the knee1. It usually presents after the child starts to walk, and is often well tolerated in children, if it is not painful. However it may present in childhood with dysfunction and instability. Very little literature is available on habitual dislocation of patella as most of the studies have combined cases of recurrent dislocation with habitual dislocation. Many different surgical techniques have been described in the literature for the treatment of habitual dislocation of patella. No single procedure is fully effective in the surgical treatment of habitual dislocation of patella and a combination of procedures is recommended.
Habitual; Dislocation; Patella
Recent advances have been made in using chondrocytes and other cell-based therapy to treat cartilage defects in adults. However, it is unclear whether these advances should be extended to the adolescent and young adult-aged patients.
We assessed cell-based surgical therapy for patellar osteochondritis dissecans (OCD) in adolescents and young adults by (1) determining function with the International Knee Documentation Committee (IKDC) subjective and Lysholm-Gillquist scores; and (2) evaluating activity level using the Tegner-Lysholm scale.
We retrospectively reviewed 23 patients between 12 and 21 years of age (mean 16.8 years) treated for OCD lesions involving the patella from 2001 to 2008. Twenty patients had autologous chondrocyte implantation and three patients had cultured bone marrow stem cell implantation. There were 19 males and four females. We obtained preoperative CT scans to assess patella subluxation, tilt, and congruence angle to determine choice of treatment. We obtained IKDC subjective knee evaluation scores, Tegner-Lysholm activity levels, and Lysholm-Gillquist knee scores preoperatively and at 6, 12, and 24 months postoperatively.
Mean IKDC score, Tegner-Lysholm outcomes, and Lysholm-Gillquist scale improved from 45, 2.5, and 50, respectively, at surgery to 75, 4, and 70, respectively, at 24-month followup. Complications include periosteal hypertrophy observed in two patients.
Cell-based therapy was associated with short-term improvement in function in adolescents and young adults with patellar OCD.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
One major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.
The primary purpose of this article is to describe our technique of a transphyseal ACL reconstruction using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that with our proposed technique no significant growth disturbances would occur.
From January 1997 to December 2007 49 consecutive children and adolescents with open growth plates were treated for a torn ACL using the aforementioned surgical technique. The patients (28 males and 21 females) with a median age at surgery of 13 (range 8-15) years were retrospectively evaluated. Outcome measures were follow-up radiographs (weight-bearing long leg radiographs of the injured and uninjured knee, anteroposterior and lateral views, a tangential view of the patella and a tunnel view of the injured knee) and follow-up notes (6 weeks, 3, 6, 12 months and until closing of physes) for occurrence of any tibial and/or femoral growth changes.
Results: All of the 49 patients had a sufficient clinical and radiological follow-up (minimum 5 years, rate 100%). 48 cases did not show any clinical and radiological growth disturbance. One case of growth disturbance in a 10.5 years old girl was observed. She developed a progressive valgus-flexion deformity which was attributed to a malplacement of the autograft bone block within the femoral posterolateral epiphyseal plate leading to an early localized growth stop. None of the patients were reoperated due to ACL graft failure. Five of the patients underwent revision ACL surgery due to another adequate sports trauma after the growth-stop. The tibial fixation screw had to be removed under local anaesthesia in 10 patients.
The described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.
transphyseal drilling; quadriceps tendon autograft; arthroscopy; ACL reconstruction; ACL tear
A retrospective study concerning patients presenting with patella instability, treated using a Roux-Elmslie-Trillat reconstruction operation and followed up for 10 years following surgery, is presented.
Pre-operative and follow-up radiographic evaluation included the weight-bearing anteroposterior and merchant views. Evaluation was carried out using the Insall-Salvati index, sulcus and congruence angle. The Roux-Elmslie-Trillat reconstruction operation was performed on 18 patients. The clinical evaluation at follow-up was performed using the Knee-Society-Score (KSS) and Tegner-Score.
Subjective results of the operation were classed as excellent or good in 16 of the 18 patients ten years after surgery; persistent instability of the patella was recorded in only one of the 18 patients. The majority of patients returned to the same level of sporting activity after surgery as they had participated in before injury.
The Roux-Elmslie-Trillat procedure could be recommended in cases presenting with an increased q-angle, trochlea dysplasia or failed soft tissue surgery. In the present study the majority of patients report a return to previous sporting activity ten years after surgery.
Complex cartilage lesions of the knee including large cartilage defects, kissing lesions, and osteoarthritis (OA) represent a common problem in orthopaedic surgery and a challenging task for the orthopaedic surgeon. As there is only limited data, we performed a prospective clinical study to investigate the benefit of autologous chondrocyte implantation (ACI) for this demanding patient population.
Fifty-one patients displaying at least one of the criteria were included in the present retrospective study: (1.) defect size larger than 10 cm2; (2.) multiple lesions; (3.) kissing lesions, cartilage lesions Outerbridge grade III-IV, and/or (4.) mild/moderate osteoarthritis (OA). For outcome measurements, the International Cartilage Society's International Knee Documentation Committee's (IKDC) questionnaire, as well as the Cincinnati, Tegner, Lysholm and Noyes scores were used. Radiographic evaluation for OA was done using the Kellgren score.
Results and Discussion
Patient's age was 36 years (13-61), defects size 7.25 (3-17.5) cm2, previous surgical procedures 1.94 (0-8), and follow-up 30 (12-63) months. Instruments for outcome measurement indicated significant improvement in activity, working ability, and sports. Mean ICRS grade improved from 3.8 preoperatively to grade 3 postoperatively, Tegner grade 1.4 enhanced to grade 3.39. The Cincinnati score enhanced from 25.65 to 66.33, the Lysholm score from 33.26 to 64.68, the Larson score from 43.59 to 79.31, and Noyes score from 12.5 to 46.67, representing an improvement from Cincinnati grade 3.65 to grade 2.1. Lysholm grade 4 improved to grade 3.33, and Larson grade 3.96 to 2.78 (Table 1), (p < 0.001). Patients with kissing cartilage lesions had similar results as patients with single cartilage lesions.
Mean scores and grades at surgery (Tx) and at follow-up
Our results suggest that ACI provides mid-term results in patients with complex cartilage lesions of the knee. If long term results will confirm our findings, ACI may be a considered as a valuable tool for the treatment of complex cartilage lesions of the knee.
Multiple epiphyseal dysplasia (MED) is one of the more common generalised skeletal dysplasias. Due to its clinical heterogeneity diagnosis may be difficult. Mutations of at least six separate genes can cause MED. Joint deformities, joint pain and gait disorders are common symptoms.
We report on a 27-year-old male patient suffering from clinical symptoms of autosomal recessive MED with habitual dislocation of a multilayered patella on both sides, on the surgical treatment and on short-term clinical outcome. Clinical findings were: bilateral hip and knee pain, instability of femorotibial and patellofemoral joints with habitual patella dislocation on both sides, contractures of hip, elbow and second metacarpophalangeal joints. Main radiographic findings were: bilateral dislocated multilayered patella, dysplastic medial tibial plateaus, deformity of both femoral heads and osteoarthritis of the hip joints, and deformity of both radial heads. In the molecular genetic analysis, the DTDST mutation g.1984T > A (p.C653S) was found at the homozygote state. Carrier status was confirmed in the DNA of the patient's parents. The mutation could be considered to be the reason for the patient's disease. Surgical treatment of habitual patella dislocation with medialisation of the tibial tuberosity led to an excellent clinical outcome.
The knowledge of different phenotypes of skeletal dysplasias helps to select genes for genetic analysis. Compared to other DTDST mutations, this is a rather mild phenotype. Molecular diagnosis is important for genetic counselling and for an accurate prognosis. Even in case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity.
According to the literature, closing and opening wedge high tibial valgus osteotomies can raise or lower the patella, and diffèrent methods of patella height measurement show similarly conflicting results. Clarification of this was thought to be important because there is much literature describing morbidity secondary to patella alta or patella infera (baja). Effects on tibial slope and patellar tendon length are not well delineated and the influence of sex and age is unknown.
A group of patients who underwent high tibial valgus osteotomy was investigated to determine how surgical technique influenced postoperative (1) patellar height and (2) tibial slope and patellar tendon length, and (3) whether age or gender independently influenced postoperative patellar height. To eliminate the often conflicting results seen when several ratio methods are used, patellar height was measured by one method, before and after surgery, shown previously to be reliable.
Patellar height was measured on radiographs using the plateau-patella angle in a retrospective case series consisting of three cohorts: 18 patients with closing wedge osteotomies, 26 with opening wedge osteotomies, and 32 with combined osteotomies. The indication for surgery in all three cohorts was medial osteoarthritis with secondary varus. Before surgery there were no significant differences in patellar height, femorotibial angle, age, or gender among the three groups, and no patients were lost to followup during the 8-week study period after surgery. Seven of the 76 patients (9.2%), all in the opening wedge cohort, had concomitant ACL reconstruction at the time of the tibial osteotomy. No other surgery, except arthroscopy, was performed at the time of osteotomy. Patellar tendon length was assessed by the Insall-Salvati index and tibial slope by the angle between the posterior tibial cortex and the medial tibial joint line. Postoperative measurements were made between 6 and 8 weeks. The influence of sex and age was calculated using patellar height measurements made before any surgery.
All closing wedge osteotomies produced patellar ascent by an average of 13% (p < 0.001), all opening wedges produced descent by an average of 21% (p < 0.001), and the combined osteotomy mean showed minimal change (p = 0.0034). The absolute consistency of the changes and their direction allow suggested guidelines for selection of osteotomy type. There were only slight changes in tibial slope. A significant change in patellar tendon length was seen in seven knees of the opening wedge cohort that had concomitant ACL reconstruction. All had a mean reduction of the Insall-Salvati index of 0.05 (approximately 5%), p = 0.0002. New findings showed higher patellae in female and older patients, unrelated to the surgery.
If it is accepted that patella baja and patella alta should be avoided, then closing wedge osteotomies should be performed only when the patella is low riding, and opening wedge osteotomies should be done only for patients with preexisting patella alta. The combined osteotomy minimizes changes in patellar height. Patellar tendon contractures and tibial slope changes can be avoided. The plateau-patella angle should be measured preoperatively to help decide the type of osteotomy.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
The aim of the present study was to evaluate incidence, degree and impact of tibial tunnel widening (TW) on patient-reported long-term clinical outcome, knee joint stability and prevalence of osteoarthritis (OA) after isolated anterior cruciate ligament (ACL) reconstruction. On average, 13.5 years after ACL reconstruction via patella-bone-tendon-bone autograft, 73 patients have been re-evaluated. Inclusion criteria consisted of an isolated anterior cruciate ligament rupture and reconstruction, a minimum of 10-year follow-up and no previous anterior cruciate ligament repair or associated intra-articular lesions. Clinical evaluation was performed via the International Knee Documentation Committee (IKDC) score and the Tegner and Lysholm scores. Instrumental anterior laxity testing was carried out with the KT-1000™ arthrometer. The degree of degenerative changes and the prevalence of osteoarthritis were assessed with the Kellgren-Lawrence score. Tibial tunnel enlargement was radiographically evaluated on both antero-posterior and lateral views under establishment of 4 degrees of tibial tunnel widening by measuring the actual tunnel diameters in mm on the sclerotic margins of the inserted tunnels on 3 different points (T1–T3). Afterwards, a conversion of the absolute values in mm into a 4 staged ratio, based on the comparison to the results of the initial drill-width, should provide a better quantification and statistical analysis. Evaluation was performed postoperatively as well as on 2 year follow-up and 13 years after ACL reconstruction. Minimum follow-up was 10 years. 75% of patients were graded A or B according to IKDC score. The mean Lysholm score was 90.2±4.8 (25–100). Radiological assessment on long-term follow-up showed in 45% a grade I, in 24% a grade II, in 17% a grade III and in additional 12% a grade IV enlargement of the tibial tunnel. No evident progression of TW was found in comparison to the 2 year results. Radiological evaluation revealed degenerative changes in sense of a grade II OA in 54% of patients. Prevalence of a grade III or grade IV OA was found in 20%. Correlation analysis showed no significant relationship between the amount of tibial tunnel enlargement (P>0.05), long-term clinical results, anterior joint laxity or prevalence of osteoarthritis. Tunnel widening remains a radiological phenomenon which is most commonly observed within the short to midterm intervals after anterior cruciate ligament reconstruction and subsequently stabilises on mid and long- term follow-up. It does not adversely affect long-term clinical outcome and stability. Furthermore, tunnel widening doesn't constitute an increasing prevalence of osteoarthritis.
anterior cruciate ligament reconstruction; long-term follow-up; IKDC-score; tibial tunnel widening; osteoarthritis; long-term anterior laxity.
This case report describes a rare case of recurrent dislocation of the patella which was accompanied with trochlear dysplasia and malalignment of the patella in a 15-year-old girl. She complained of hemoarthrosis and recurrent patellar dislocation in the early knee flexion phase. Plain radiography and computed tomography (CT) showed patellar malalignment (quadriceps angle 20°) and severe dysplasia of the trochlea of the femur (sulcus angle 170°). Surgery was performed, consisting of trochleoplasty in addition to proximal and distal realignment. Trochleoplasty was undertaken using a modified Dejour technique. After surgery, the patient complained of joint contracture. Arthroscopic release of fibrous tissue relieved symptoms and obtained normal range of motion without patellar dislocation. Postoperative radiography and CT demonstrated improvement of the quadriceps angle (10°) and sulcus angle (140°).
Dislocations; knee; patella
The purpose of this study was to evaluate reconstruction of the medial patellofemoral ligament (MPFL) using the double-bundle anatomical or single-bundle isometric procedure with respect to the patients’ clinical outcomes.
In this retrospective study, we evaluated the clinical outcome of double-bundle anatomical versus single-bundle isometric reconstruction of the MPFL for patellar dislocation patients. Sixty-three patients were included in this study from August 2004 to January 2008. From August 2004 to September 2006, MPFL reconstruction using a single-bundle isometric technique was performed in 21 patients (26 knees). Since October 2006, the double-bundle anatomical reconstruction of the MPFL has been used as the routine surgical procedure. It was performed in 37 patients (44 knees). Fifty-eight patients (70 knees) could be followed up. According to the different techniques, we divided the patients into two groups: group D with double-bundle anatomical reconstruction (37 patients) and group S with single-bundle isometric reconstruction (21 patients). Clinical evaluation consisted of the number with a patellar re-dislocation, patellar apprehension sign, Kujala score, subjective questionnaire score, the patella lateral shift rate and patellar tilt angle measured by cross-sectional CT scan.
According to the Kujala score and the subjective questionnaire score, the outcome of the double-bundle group was better than the outcome of the single-bundle group especially in the long-term. Patellar re-dislocation occurred in three patients in the group S, while no re-dislocation occurred in the group D. In total, 26.9 % of group S was considered to have patellar instability, compared to 4.54 % of the group D. After operation, the patellar tilt angle (PTA) and the patella lateral shift rate (PLSR) were restored to the normal range, with statistical significance (P < 0.05) compared to the preoperative state.
Single- and double-bundle reconstruction of the MPFL can both effectively restore patella stability and improve knee function. However, outcomes in the follow-up period showed that the double-bundle surgery procedure was much better than in single-bundle surgery.
To evaluate the clinical and functional results of surgical treatment of patellar dislocation in children.
Material and methods
A prospective study was undertaken from January 1995 to December 2004. Patients who suffered from patellar dislocation after receiving intramuscular antibiotic injections to quadriceps were recruited. A complete history of each patient was recorded, and both a clinical and a roentgenographic examination were performed preoperatively. Patellar dislocation was classified according to Bensahel’s criteria. The iliotibial tract and lateral retinacula was released to restore the tension of the medial retinaculum. Quadricepsplasty was used in all patients for full flexion of knee.
There were nine males and 65 females in this study. All 74 patients (76 knees) developed dislocation of the patella after repeated intramuscular injections of antibiotic(s) into the quadriceps muscle. Fifty-six knees (73.7%) were type 1, and 20 knees (26.3%) were type 2 (Bensahel’s classification). In all, we attained excellent results in 56 knees (73.7%), good results in 17 knees (22.4%), and fair results in three knees (3.9%). There have been no poor results or recurrences so far.
Use of the iliotibial tract, adequate lateral retinacular release, restoration of the tension of the medial retinaculum and associated quadricepsplasty achieved a high success rate. The technique is simple, safe and effective in skeletally immature children.
Patella instability; Habitual dislocation of the patella; Subluxation of the patella; Developmental dysplasia of patella (DDP); Malformative dislocation