Robert A. Teitge

Medial Patellofemoral Ligament Reconstruction in Patients With Lateral Patellar Instability and Trochlear Dysplasia

Background Reconstruction of the medial patellofemoral ligament has been proven to restore stability in patients with lateral patellar instability. No study to date has examined the results in a patient population with the predisposing factor of femoral trochlear dysplasia. Hypothesis Reconstruction of the medial patellofemoral ligament restores stability and provides pain relief in patients who have lateral patellar instability in association with trochlear dysplasia. Study Design Case series; Level of evidence, 4. Methods Thirty-four patients with chronic patellar instability and trochlear dysplasia were treated with medial patellofemoral ligament reconstruction using an adductor tendon autograft, bone–quadriceps tendon autograft, or bone–patellar tendon allograft. All patients were evaluated preoperatively and postoperatively with Kujala, Lysholm, and Tegner scores at a minimum of 24 months. Results Thirty-four patients were followed for a mean of 66.5 months (range, 24-130 months) after surgery. Kujala scores improved from 53.3 to 90.7, Lysholm scores improved from 52.4 to 92.1, and Tegner activity scores improved from 3.1 to 5.1. All improvements were highly statistically significant (P < .001). No statistical difference was found between the postoperative Lysholm, Kujala, and Tegner scores and the degree of dysplasia, graft type, or degree of symptoms. There were 85.3% and 91.1% good and excellent results based on Kujala and Lysholm scores, respectively. No recurrent dislocations have occurred. Conclusion Medial patellofemoral ligament reconstruction provides excellent long-term pain relief and functional return in patients with patellar instability and femoral trochlear dysplasia. In addition, reconstruction prevents recurrent dislocation, despite the diminished bony constraint of a dysplastic trochlea.

Synovial thickening detected by MR imaging in osteoarthritis of the knee confirmed by biopsy as synovitis

Previous studies have established the value of magnetic resonance imaging (MRI) in detecting articular changes characteristic of osteoarthritis (OA) of the knee. We have observed some MRI features in OA of the knee presumably indicating synovial thickening. To determine whether these MR features represent chronic synovial inflammation, we studied the knees of nine patients at the mild end of the spectrum of OA of relatively short duration (89%: < or = 4 yr), who were selected because MRI showed anatomical abnormalities compatible with synovial thickening. The painful knee was examined using conventional and weight-bearing radiographs, MRI, and arthroscopy. MR images suggestive of synovial thickening typically appeared in or near the intercondylar region of the knee, in the infrapatellar fat pad, or in the posterior joint margin. The site of an arthroscopic biopsy of the synovial membrane was guided by MRI to the area thought to represent synovial thickening for each patient knee. Pathological examination of these synovial membrane biopsies showed a mild chronic synovitis, and thus a correspondence with the synovial thickening detected by MRI. Our results suggest that MRI can be used to evaluate the extent of synovitis, observed as synovial thickening, in patients with early OA of the knee.

Rupture of the distal insertion of the biceps brachii tendon.

Rupture of the distal insertion of the biceps brachii tendon is a rare injury. There has been no unanimity in the literature concerning the best method of repair. Between March 1981 and July 1984, 14 ruptures (12 acute and two late) were repaired using a modification of the Boyd-Anderson technique. Cybex testing of the elbow flexion by applying an eccentric load demonstrated that strength and endurance in the repaired dominant arm were roughly equal to the noninjured, non-dominant arm, but that strength and endurance of the repaired nondominant arm were only 64% and 50%, respectively, of the noninjured dominant arm. Surgical repair is a safe procedure that yields consistently good results.

The Female Knee: Anatomic Variations and the Female-specific Total Knee Design

AbstractThe concept and need for a gender-specific or female-specific total knee prosthesis have generated interest and discussion in the orthopaedic community and the general public. This concept relies on the assumption of a need for such a design and the opinion that there are major anatomic differences between male and female knees. Most of the information regarding this subject has been disseminated through print and Internet advertisements, and through direct-to-patient television and magazine promotions. These sources and a recent article in a peer-reviewed journal, which support the need for a female-specific implant design, have proposed three gender-based anatomic differences: (1) an increased Q angle, (2) less prominence of the anterior medial and anterior lateral femoral condyles, and (3) reduced medial-lateral to anterior-posterior femoral condylar aspect ratio. We examined the peer-reviewed literature to determine whether women have had worse results than men after traditional TKAs. We found women have equal or better results than men. In addition, we reviewed the evidence presented to support these three anatomic differences. We conclude the first two proposed differences do not exist, and the third is so small that it likely has no clinical effect. Level of Evidence: Level IV, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.

MR features of osteoarthritis of the knee

A group of patients with idiopathic osteoarthritis (OA) of the knee was surveyed using weight-bearing radiographs and MR imaging to compare the relative value of these methods in disease evaluation. Fifty-two patients with a clinical and radiological diagnosis of OA of the knee of relatively short duration (87%: < or = 4 yr) were compared to a reference group of 40 age- and sex-comparable subjects with no knee symptoms. All patients had a complete history, physical examination, standard anterior-posterior and lateral weight-bearing radiographs, T1-weighted, and FLASH MR images in both knees. The prevalence of MRI abnormalities was significantly greater in patients with OA of the knee in all radiographic grades (Kellgren and Lawrence) compared to the reference subjects. Significant differences were encountered for synovial thickening (OA, 73%; reference, 0%), synovial fluid (60%; 7%), meniscal degeneration (52%; 7%), osteophytes (67%; 12%), and subchondral bone involvement (65%; 7%), even in the patients at the mild end of the osteoarthritic spectrum, indicating the exquisite sensitivity of MRI compared with weight-bearing radiographs.

Fresh osteochondral allografts for patellofemoral arthritis: long-term followup.

Treatment of patellofemoral osteoarthritis in young patients is a challenge for orthopaedic surgeons. Concern about loosening and wear in active young people render arthroplasty more suitable for older patients. Osteochondral allografts may be a good alternative, but reports of experience with such grafts in patellofemoral joints are limited. We retrospectively reviewed our results with fresh osteochondral allografts. Our hypothesis was that these grafts provide relief from osteoarthritis, improve knee function, and delay prosthetic knee replacement. From 1986 to 1999, 14 fresh patellofemoral or patellar allografts were implanted in knees of 11 patients younger than 55 years and diagnosed with advanced secondary osteoarthritis. At last followup (average, 10 years; range, 2.5-17.5 years), eight grafts were in place, four for more than 10 years and two for more than 5 years. Of the nonsurviving allografts, three survived more than 10 years. Radiographs of the knees with intact allografts showed mild or no degenerative changes. Average Knee Society scores improved (preoperative to last followup), with knee scores improving from 46 points (range, 38-60 points) to 82 points (range, 35-100 points) and functional scores from 30 points (range, 10-60 points) to 75 points (range, 20-100 points). Fresh osteochondral allografts can provide relief from the arthritic condition, improve knee function, and delay prosthetic knee replacement.Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

The quantitative measurement of normal passive medial and lateral patellar motion limits

To quantify normal motion, medial and lateral passive patellar motion limits were measured in 67 high school athletes randomly selected from a group of 1340 ath letes undergoing preseason physical examinations. Pa tellar displacement was measured at knee flexion an gles of 0° and 35°, using both a Patella Pusher (a hand held force gauge) and a manual technique, and the results were compared. Demographic data and physical examination of the deceleration mechanism (Q angle, vastus medialis obliquus dysplasia, patella alta and baja, and valgus and varus alignment) were correlated with patellar motion limits. With the knee in extension, passive displacement of the patella averaged 9.6 mm medially and 5.4 mm laterally. In flexion, medial displacement averaged 9.4 mm and lateral displacement averaged 10.0 mm. No positive correlations were found between demographic data or deceleration mechanism examination parame ters and patellar motion limits, suggesting that motion produced by the displacement force was limited by ligamentous restraints only. The clinical assessment of the passive limits of pa tellar motion should include examination at knee flexion angles of 0° and 35°. The manually produced displace ment was found to be more reproducible than displace ment by the Patella Pusher (P < 0.05).

Stabilization of the Clavicle After Distal Resection A Biomechanical Study

Background The potential destabilizing effect of distal clavicle resection has received limited attention. Hypothesis Suturing the coracoacromial ligament to the undersurface of the distal clavicle after resection could counter clavicle instability. Study Design Controlled laboratory study. Methods The effect of ligament augmentation on posterior translation of the clavicle after resection was evaluated using 12 fresh-frozen cadaveric shoulders. Posterior clavicular displacement was measured after the application of a 70-N load under 4 different conditions: (1) the intact joint, (2) after distal clavicle resection, (3) clavicle resection plus acromioclavicular capsular ligament repair, and (4) clavicle resection plus acromioclavicular capsular ligament repair plus coracoacromial ligament augmentation. Results Mean displacements for each of the test conditions were as follows: (1) 5.60 mm, (2) 7.38 mm, (3) 7.54 mm, and (4) 6.34 mm. A 32% increase in posterior translation was measured after resection compared to the intact specimen. No reduction in posterior displacement was noted after capsular repair; however, displacement decreased significantly when capsular repair was coupled with ligament augmentation. Conclusions Results suggest that the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation. Clinical Relevance That the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation may be particularly relevant in cases of resection for posttraumatic arthritis after acromioclavicular separation in which some degree of preexisting acromioclavicular capsular attenuation and consequently acromioclavicular joint laxity may be presumed.

Medial patellofemoral ligament reconstruction.

This article presents a simple and reproducible technique to reconstruct the medial patellotemeral ligament with autogenous tissue following the basic principles of all ligament reconstruction.

Medial dislocation of the patella

Medial dislocation of the patella is a previously unreported entity. This disorder can be disabling to the patient and may require a hospital visit for reduction. Three cases are presented in this article in which computed tomography demonstrated the dislocation. All three patients had undergone a lateral retinacular release to the involved knee for treatment of chronic knee pain or recurrent lateral patellar subluxation.