Intercondylar notch stenosis in degenerative arthritis of the knee

Clinically-Inspired Multi-Agent Transformers for Disease Trajectory Forecasting From Multimodal Data

Deep neural networks are often applied to medical images to automate the problem of medical diagnosis. However, a more clinically relevant question that practitioners usually face is how to predict the future trajectory of a disease. Current methods for prognosis or disease trajectory forecasting often require domain knowledge and are complicated to apply. In this paper, we formulate the prognosis prediction problem as a one-to-many prediction problem. Inspired by a clinical decision-making process with two agents-a radiologist and a general practitioner - we predict prognosis with two transformer-based components that share information with each other. The first transformer in this framework aims to analyze the imaging data, and the second one leverages its internal states as inputs, also fusing them with auxiliary clinical data. The temporal nature of the problem is modeled within the transformer states, allowing us to treat the forecasting problem as a multi-task classification, for which we propose a novel loss. We show the effectiveness of our approach in predicting the development of structural knee osteoarthritis changes and forecasting Alzheimer's disease clinical status directly from raw multi-modal data. The proposed method outperforms multiple state-of-the-art baselines with respect to performance and calibration, both of which are needed for real-world applications. An open-source implementation of our method is made publicly available at https://github.com/Oulu-IMEDS/CLIMATv2.

Stretching, Bracing, and Devices for the Treatment of Osteoarthritis-Associated Joint Contractures in Nonoperated Joints: A Systematic Review and Meta-Analysis

CONTEXT

Many patients with osteoarthritis (OA) develop range of motion (ROM) restrictions in their affected joints (contractures), associated with worse outcomes and rising healthcare costs. Effective treatment guidance for lost ROM in OA-affected joints is lacking.

OBJECTIVE

A systematic review and meta-analysis evaluating the effectiveness of stretching and/or bracing protocols on native (nonoperated) joint ROM in the setting of radiographically diagnosed OA.

DATA SOURCES

Seven databases, English-language.

STUDY SELECTION

Studies including participants with radiographically diagnosed OA in any native joint evaluating the effect of stretching or bracing on ROM.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Two reviewers independently screened articles for inclusion and assessed risk of bias in included trials. Primary outcomes were ROM, pain, and adverse events (AEs).

RESULTS

We identified 6284 articles. A total of 9 randomized controlled trials, all evaluating the knee, met eligibility criteria. For stretching, 3 pooled studies reported total ROM, which improved by mean difference (MD) of 9.3° (95% CI 5.0°,13.5°) versus controls. Two pooled studies showed improved knee flexion ROM (MD 10.8° [7.3°,14.2°]) versus controls. Five studies were pooled for knee extension with mean improvement 9.1° [3.4°,14.8°] versus controls. Seven pooled studies showed reduced pain (standardized MD 1.9 [1.2,2.6]). One study reported improved knee extension of 3.7° [2.9°,4.5°] with use of a device. No studies used orthoses. One study reported on AEs, with none noted. Performance bias was present in all included studies, and only 3 studies clearly reported blinding of outcome assessors. Strength of evidence for primary outcomes was considered moderate.

CONCLUSION

There was moderate-quality evidence that stretching is an effective strategy for improving knee total, flexion and extension ROM, and pain. Our findings suggest that stretching to regain joint ROM in OA is not futile and that stretching appears to be an appropriate conservative intervention to improve patient outcomes as part of a comprehensive knee OA treatment plan before arthroplasty.

Benefits and Mechanisms of Exercise Training for Knee Osteoarthritis

Knee osteoarthritis is a chronic degenerative disease. Cartilage and subchondral bone degeneration, as well as synovitis, are the main pathological changes associated with knee osteoarthritis. Mechanical overload, inflammation, metabolic factors, hormonal changes, and aging play a vital role in aggravating the progression of knee osteoarthritis. The main treatments for knee osteoarthritis include pharmacotherapy, physiotherapy, and surgery. However, pharmacotherapy has many side effects, and surgery is only suitable for patients with end-stage knee osteoarthritis. Exercise training, as a complementary and adjunctive physiotherapy, can prevent cartilage degeneration, inhibit inflammation, and prevent loss of the subchondral bone and metaphyseal bone trabeculae. Increasing evidence indicates that exercise training can improve pain, stiffness, joint dysfunction, and muscle weakness in patients with knee osteoarthritis. There are several exercise trainings options for the treatment of knee osteoarthritis, including aerobic exercise, strength training, neuromuscular exercise, balance training, proprioception training, aquatic exercise, and traditional exercise. For Knee osteoarthritis (KOA) experimental animals, those exercise trainings can reduce inflammation, delay cartilage and bone degeneration, change tendon, and muscle structure. In this review, we summarize the main symptoms of knee osteoarthritis, the mechanisms of exercise training, and the therapeutic effects of different exercise training methods on patients with knee osteoarthritis. We hope this review will allow patients in different situations to receive appropriate exercise therapy for knee osteoarthritis, and provide a reference for further research and clinical application of exercise training for knee osteoarthritis.

The morphology of the femoral footprint of the anterior cruciate ligament changes with aging from a large semicircular shape to a small flat ribbon-like shape

PURPOSE

Compare the differences in the morphology of the ACL femoral footprint between the cadavers of the young and elderly in consideration of the degenerative physiological process that occurs with aging.

METHODS

The femoral footprint of the ACL was dissected in 81 knees of known gender and age (45 male/36 female). They were divided into four groups by age and gender, establishing 50 years as the cut-off point to divide patients by age. Three observers analyzed the femoral footprint dissections, and the shapes were described and classified. The area and morphometric characteristics of the femoral insertion of the ACL were determined and these were compared between genders and age groups.

RESULTS

The femoral footprint of the ACL from the cadavers of males younger than 50 years of age presented a semicircular morphology in 90% of the cases. In males aged more than 50 years, a ribbon-like morphology was found in 96% of the cases. In women less than 50 years old, the semicircular morphology was observed in 93.7% of the cases. In women aged over 50 years old, the ribbon-like morphology was found in 95% of the cases. A significant difference was observed between the prevalence rates of the morphologies, area size and measurements of the younger and older groups (p < 0.001 for both genders).

CONCLUSIONS

The femoral insertion of the ACL presents variations in its morphology, area and morphometric characteristics over time. It goes from a large semicircular shape that almost contacts the posterior articular cartilage to a smaller, flattened ribbon-like shape that moves away from the edge of the articular cartilage. It is bounded anteriorly by the lateral intercondylar ridge. These findings should be considered to avoid employing reconstruction techniques in which femoral tunnels with oval or rectangular shapes are used in patients under 50 years of age because they do not correspond to the morphology of the femoral insertion of the ACL in this age group.

Flexion contracture can be relieved by concurrent notchplasty in medial open wedge high tibial osteotomy

BACKGROUND

Given that medial open wedge high tibial osteotomy (OWHTO) not only delays the progression of osteoarthritis but also alleviates the resulting pain, surgical outcomes would be improved if limited ROM can also be managed. In this regard, the effect of concurrent notchplasty on flexion contracture has not been evaluated.

HYPOTHESIS

(1) Concurrent notchplasty in OWHTO would relieve flexion contracture regardless of the severity of osteoarthritis and this effect would be maintained over time, and (2) concurrent notchplasty would not cause any added complications compared to the same procedure without notchplasty.

PATIENTS AND METHODS

In total, 107 patients who underwent OWHTO between 2011 and 2017 with a mean follow-up period of 46.6months (range: 24-102months) were reviewed. ROM was measured at three time points as follows: before surgery, at 6-12months postoperatively, and at the latest follow-up. The measurements were analyzed using a linear mixed model in terms of notchplasty and other factors, including age, sex, body mass index, preoperative hip-knee-ankle angle, lateral distal femoral angle, medial proximal tibial angle, correction angle, concurrent meniscectomy, postoperative posterior slope, and Kellgren-Lawrence grade. Then, ROMs at the three time points were compared between the notchplasty and non-notchplasty groups.

RESULTS

Of the 107 patients, 47 underwent concurrent notchplasty. The linear mixed model regarding flexion contracture showed a significant notchplasty-by-time interaction (p<0.001). When comparing preoperative flexion contractures between the two groups, a significant difference was found (p<0.001). At 6-12months postoperatively, flexion contractures were relieved regardless of notchplasty; however, the difference between the groups was decreased (p=0.026). At the latest follow-up, flexion contractures were partly aggravated in both groups, but no significant difference was found between the groups (p=0.461). Comparison of flexion contracture between before surgery and at the latest follow-up in each group revealed a significant difference only in the notchplasty group (p<0.001, with notchplasty; p=0.197, without notchplasty). The linear mixed model regarding maximal flexion did not show any factor having a significant interaction with time. There were no surgical complications such as infection, thromboembolic events, and hemarthrosis, in both notchplasty and non-notchplasty groups.

CONCLUSION

The preoperative difference in flexion contracture was overcome by adding notchplasty to OWHTO, and this improvement was maintained over time. No added complications were noted in the notchplasty group. The results should be interpreted with caution, considering measurement error of ROM. However, concurrent notchplasty in OWHTO deserves further study to validate its efficacy.

LEVEL OF EVIDENCE

III, retrospective cohort study.

IRB INFORMATION

Project No. S2020-0081, AMC IRB SOP.

Does Bone Regrow After Notchplasty in ACL Reconstruction? A Prospective Computed Tomography Study With 2-Year Follow-up

Background:

During notchplasty in anterior cruciate ligament (ACL) reconstruction, bone is excised from the lateral and roof area of the notch to widen the intercondylar space and avoid notch-graft impingement in extension. There are concerns that bone regrowth of the area will cause narrowing and increase the risk of complications.

Purpose:

To determine the possibility of late narrowing of the notch after notchplasty using computed tomography (CT) analysis.

Study Design:

Case series; Level of evidence, 4.

Methods:

Measurements were performed on CT scans (axial and sagittal planes with knee in extension) in patients who had undergone single-bundle anatomic ACL reconstruction using hamstring graft. Two axial image levels were used: at the anterior outlet and the anterior one-eighth level of the notch. The maximum notch height and width, the notch width at one-third and two-thirds of the preoperative notch midwidth height, the maximum condylar width, and the surface area of the lateral half of the notch were measured preoperatively and at 1 week and 2 years postoperatively.

Results:

Included were 20 consecutive patients (mean ± standard deviation age, 28 ± 7.3 years; follow-up, 24.2 ± 3.3 months). At the anterior notch outlet, the maximum notch width increased by 1.9 ± 1.7 mm at 1 week postoperatively and narrowed by 0.3 ± 1.1 mm at the final follow-up, while the maximum notch height increased by 1.7 ± 1.9 mm and narrowed by 0.8 ± 1.8 mm, respectively. At one-eighth of the roof length, the maximum notch width increased by 1.1 ± 1.7 mm at 1 week postoperatively and narrowed by 0.1 ± 1.1 mm at the final follow-up, and the maximum notch height increased by 1.2 ± 1.5 mm and narrowed by 0.5 ± 1.5 mm, respectively. All differences were statistically significant when comparing the pre- to the immediate postoperative measurements, and they were nonsignificant when comparing the immediate postoperative to the final follow-up measurements. The same applied for the ratio of maximum notch width to maximum condylar width, indicating no postoperative narrowing of the notch.

Conclusion:

Notch size-shape after a 2-mm notchplasty did not change significantly in stable knees during the first 2 years after anatomic ACL reconstruction. Surgeons should consider performing this adjuvant technique when there is notch-graft impingement during surgery.

The intercondylar fossa-A narrative review

The intercondylar fossa (“intercondylar notch,” IN) is a groove at the distal end of the femur, housing important stabilizing structures: cruciate ligaments and meniscofemoral ligaments. As the risk for injury to these structures correlates with changes to the IN, exact knowledge of its morphology, possible physiological and pathological changes and different approaches for evaluating it are important. The divergent ways of assessing the IN and the corresponding measurement methods have led to various descriptions of its possible shapes. Ridges at the medial and lateral wall are considered clinically important because they can help with orientation during arthroscopy, whereas ridges at the osteochondral border could affect the risk of ligament injury. Changes related to aging and sex differences have been documented, further emphasizing the importance of individual assessment of the knee joint. Overall, it is of the utmost importance to remember the interactions between the osseous housing and the structures within.

Effects of Notchplasty on Anterior Cruciate Ligament Reconstruction: A Systematic Review

Purpose  Notchplasty is a complementary surgical procedure often performed during anterior cruciate ligament reconstruction (ACLR) with the aim to widen the intercondylar notch and to avoid graft impingement. The aim of this review was to analyze the current literature evidence concerning the effects of notchplasty on clinical outcome after primary ACLR.

Methods  Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE were used to search English language studies, from January 1990 to July 2015, concerning the effects of the notchplasty on ACLR, using the following keywords: “ACL” OR “anterior cruciate ligament” OR “ACL reconstruction” OR “anterior cruciate ligament reconstruction” AND “notch” OR “notchplasty” OR “intercondylar notch”. Randomized and nonrandomized trials, case series, technical notes, biomechanical studies and radiological study were included.

Results  At the final screening 16 studies were included. Despite widely used, the usefulness of notchplasty during ACLR remains unclear. Some concerns emerged regarding potential harmful effects of notchplasty, mostly related to the knee biomechanics and postoperative blood loss. Notchplasty can be useful in the treatment of arthrofibrosis and in presence of bony spurs of the notch both in primary and revision surgery. However, the level of evidence of available literature is poor and there is a strong need for randomized controlled trials investigating the role of notchplasty on ACLR.

Conclusion  We suggest being aware of potential complications following notchplasty during ACLR before deciding to perform notchplasty in primary ACLR, reserving it for the surgical management of arthrofibrosis, treatment of notch osteophytosis and revision ACLR.

Level of Evidence  Level IV, systematic review of level II-IV studies.

Notchplasty for the Arthroscopic Treatment of Limited Knee Extension

Knee osteoarthritis may lead to narrowing of the intercondylar notch due to osteophyte formation, thereby causing changes in native knee biomechanics. The normal close contact between the condyles and the anterior cruciate ligament (ACL) during knee extension may be compromised due to narrowing of the notch and result in ACL damage, progression of knee osteoarthritis, and loss of knee extension. Outcomes after a notchplasty procedure are well reported for ACL reconstruction in young patients. However, there remains a lack of studies evaluating this procedure in the setting of knee osteoarthritis in patients with a symptomatic loss of knee extension. The purpose of this Technical Note is to present our preferred surgical technique for the treatment of loss of knee extension in the setting of knee osteoarthritis in conjunction with osteophyte formation in the intercondylar notch.

Intercondylar Notch Stenosis of Knee Osteoarthritis and Relationship between Stenosis and Osteoarthritis Complicated with Anterior Cruciate Ligament Injury: A Study in MRI

The aim of this study was to research whether the patients with knee osteoarthritis (OA) exist intercondylar notch stenosis and the relationship between stenosis and OA complicated with anterior cruciate ligament (ACL) injury from magnetic resonance imaging (MRI).A total of 79 cases of moderate-severe OA patients and 71 cases of healthy people were collected; among these OA patients, 38 were OA complicated with ACL injury and 41 were simple OA. The intercondylar notch was divided into A, U, and W types according to the notch shape in the axial sequence of MRI. Measurement of the notch width index (NWI) in the sequences of axial (NWI-1), coronal (NWI-2), and ACL attachment point at femoral (NWI-A) was done. The differences of NWI in different groups and different sequences were compared and the NWI cut-off values in different sequences were resolved by a receiver operating characteristic (ROC) curve which could be used as indicators for intercondylar notch narrowing were calculated.The proportion of type A in moderate-severe OA group was larger than healthy group, and similar to OA complicated with ACL injury and simple OA groups (P <0.05). The NWI values of the moderate-severe OA group in three sequences were smaller than the healthy group, and similar to OA complicated with ACL injury and simple OA groups (P <0.001). The cut-off values of ROC curve were NWI-1 <0.266, NWI-2 <0.247, and NWI-A <0.253 in the moderate-severe OA group, and NWI-1 <0.263, NWI-2 <0.246, and NWI-A <0.253 in the OA complicated with ACL injury group. The intercondylar notch of moderate-severe OA patients exist significant stenosis. Type A is one of the variables that predispose a notch to stenosis. Intercondylar notch stenosis and type A are risk factors for moderate-severe OA patients complicated with ACL injury.

Indications for and results of arthroscopy in the arthritic knee: a European survey

PURPOSE

The place of arthroscopic treatment in osteoarthritis of the knee has generated much controversy. A survey was initiated to collect the opinion of experienced surgeons.

METHODS

Of the 211 surgeons interviewed, 170 (80.6%) replied to the electronic questionnaire. Respondents had at least ten years of experience in arthroscopy and currently perform more than 100 arthroscopies per year. Various indications and treatment modalities for arthroscopy in osteoarthritis of the knee had to be evaluated on a scale from "excellent" to "no indication".

RESULTS

The respondents generally believe that an improvement is more likely in low-grade osteoarthritis (p < 0.001) and in neutral leg axis (p < 0.001). The outcome was rated better if symptoms had persisted for less than six months (p < 0.001) and for patients that were younger than 60 years (p < 0.001). Partial meniscectomy and notchplasty in cases of extension deficit were considered as successful treatment options. Debridement was an accepted indication, with an outcome mainly rated as fair. A majority saw no indication for joint lavage, arthroscopic treatment of arthrofibrosis and removal of osteophytes. The outcome appears to be poor if a bone edema is diagnosed on magnetic resonance imaging prior to arthroscopy. Only 55.9% of respondents were comfortable with the current definition of osteoarthritis.

CONCLUSIONS

Experienced arthroscopic surgeons all over Europe believe arthroscopy in osteoarthritis is appropriate, under certain conditions. The major task for surgeons is to select the right patients who are likely to benefit from this intervention.

Anterior cruciate ligament changes in the human knee joint in aging and osteoarthritis

OBJECTIVE

The development and patterns of spontaneous age-related changes in the anterior cruciate ligament (ACL) and their relationship to articular cartilage degeneration are not well characterized. This study was undertaken to investigate the types and temporal sequence of age-related ACL changes and to determine their correlation with cartilage lesion patterns at all stages of osteoarthritis (OA) development in human knee joints without prior joint trauma.

METHODS

Human knee joints (n = 120 from 65 donors ages 23-92) were obtained at autopsy, and ACLs and cartilage were graded macroscopically and histologically. Inflammation surrounding the ACL was assessed separately.

RESULTS

Histologic ACL substance scores and ligament sheath inflammation scores increased with age. Collagen fiber disorganization was the earliest and most prevalent change. The severity of mucoid degeneration and chondroid metaplasia in the ACL increased with the development of cartilage lesions. A correlation between ACL degeneration and cartilage degeneration was observed, especially in the medial compartment of the knee joint.

CONCLUSION

Our findings indicate that ACL degeneration is highly prevalent in knees with cartilage defects and may even precede cartilage changes. Hence, ACL deficiencies may not only be important in posttraumatic OA, but may also be a feature associated with knee OA pathogenesis in general.

Histological evaluation and comparison of the anteromedial and posterolateral bundle of the human anterior cruciate ligament of the osteoarthritic knee joint

A human anterior cruciate ligament (ACL) is composed of an anteromedial (AM) and posterolateral (PL) bundle which have different biomechanical functions. ACL degeneration and ACL deficiency often occur in patients with osteoarthritis (OA); however, histological evaluation of each bundle of the ACL in the OA knee has not been reported. Our objective was to compare the degenerative changes of the AM and PL bundle in the OA knee based on histological appearance. A histological evaluation of the AM and PL bundle from 49 varus OA knees was performed. Fifty-three percent of the AM bundle and 78% of the PL bundle showed severe histological degenerative changes. The degenerative changes were statistically more severe in the PL bundles than the AM bundles (p<0.05). Since the cross sectional area of the AM bundle is larger than that of the PL bundle and the pattern of length change of the PL bundle is greater than that of the AM bundle, it would logically follow that the PL bundle would show more severe degenerative changes than the AM bundle. This study identified the histological appearance of the bundles of the ACL of the OA knee and may help to elucidate the process of ACL degeneration in the OA knee.

The relation of femoral notch stenosis to ACL tears in persons with knee osteoarthritis

OBJECTIVE

A significant risk factor for anterior cruciate ligament (ACL) tears in young athletes is a reduced femoral Notch Width Index (NWI). The purpose of this study was to test if persons with knee osteoarthritis (OA) and ACL tears have smaller NWI independent of prior joint injury and osteophyte volume.

METHODS

We included 160 participants from the progression sub-cohort of the Osteoarthritis Initiative (OAI) Study, an ongoing 4-year, multi-center study, focusing on knee OA. The femoral notch width, the condylar notch width at 2/3 of the notch depth, and the intercondylar notch angle (beta) were measured on sagittal and coronal MR-images. NWI=notch width/condylar width at 2/3 of the notch depth, was calculated and outcome of ACL tear frequency was compared between two groups; NWI<or=0.20 and NWI>0.20. The NWI and beta were analyzed as continuous variables.

RESULTS

Of the 160 subjects [51% female, age 62.1 (+/-9.9), BMI 30.3 (+/-4.7)kg/m(2)] 14.4% showed an ACL tear. Osteophyte bone volume was available for 150 participants, of which 13% had an ACL tear. The continuous measure of NWI on the coronal images was significantly (P=0.01) smaller in participants with ACL tear [0.246, 95% confidence interval (CI) 0.234-0.258] compared to those without (0.263, 95% CI 0.258-0.268). Adjustment for demographic variables still showed significant results (P=0.03, mean difference 0.015 95% CI -0.001-0.030) and adjustment for demographic variables and osteophyte bone volume were borderline significant (P=0.06, mean difference 0.015 95% CI 0.001-0.029).

CONCLUSIONS

We identified a smaller NWI in participants with knee OA and ACL tears. Further longitudinal investigation is necessary to determine this as an independent risk factor.

Complete anterior cruciate ligament tear and the risk for cartilage loss and progression of symptoms in men and women with knee osteoarthritis

OBJECTIVE

To determine whether a complete anterior cruciate ligament (ACL) tear, a frequent incidental finding on magnetic resonance imagings (MRIs) of individuals with established knee osteoarthritis (OA), increases the risk for further knee OA progression.

METHODS

We examined 265 participants (43% women) with symptomatic knee OA in a 30-month, prospective, natural history study of knee OA. The more symptomatic knee was imaged using MRI at baseline, 15 and 30 months. Cartilage was scored at the medial and lateral tibiofemoral joint and at the patellofemoral joint using the Whole-Organ MRI Score (WORMS) semi-quantitative method. Complete ACL tear was determined on baseline MRI. At each visit, knee pain was assessed using a knee-specific visual analog scale and physical function was assessed using the Western Ontario and McMaster Universities (WOMAC) physical function subscale.

RESULTS

There were 49 participants (19%) with complete ACL tear at baseline. Adjusting for age, body mass index, gender and baseline cartilage scores, complete ACL tear increased the risk for cartilage loss at the medial tibiofemoral compartment [odds ratio (OR): 1.8, 95% confidence interval (CI): 1.1, 3.2]. However, following adjustment for the presence of medial meniscal tears, no increased risk for cartilage loss was further seen (OR: 1.1, 95% CI: 0.6, 1.8). Knee pain and physical function were similar over follow-up between those with and without a complete ACL tear.

CONCLUSIONS

Individuals with knee OA and incidental complete ACL tear have an increased risk for cartilage loss that appears to be mediated by concurrent meniscal pathology. The presence of a complete ACL tear did not influence the level of knee pain or physical function over short-term follow-up.

Arthroscopic treatment of mucoid hypertrophy of the anterior cruciate ligament

PURPOSE

The purpose of this study was to examine the clinical features and diagnosis of patients with mucoid hypertrophy of the anterior cruciate ligament (ACL) and to assess the results of arthroscopic treatment.

METHODS

Between May 1999 and August 2005, 156 knees in 132 patients were diagnosed with mucoid hypertrophy of the ACL and underwent arthroscopic treatment. Of these, 106 knees in 91 patients (86 women and 5 men), with a mean age of 61 years (range, 42 to 80 years), were followed up for at least 2 years. All 106 knees had central knee pain on terminal extension without preceding trauma, and 83 (78.3%) had extension deficit. Magnetic resonance imaging showed thickened, ill-defined ACLs with increased intraligamentous signals. Arthroscopy showed osteoarthritic changes of varying degrees in all, with 84 (79.2%) having intercondylar notch narrowing and 102 (96.2%) having additional degenerative pathologies. The posterolateral portion of the ACL appeared hypertrophied, which impinged on the lateral wall and roof of the notch. Arthroscopic debridement of hypertrophied ACLs was performed with or without notchplasty, according to the severity of impingement.

RESULTS

Good to excellent pain relief on terminal extension was obtained in 92 of 106 knees (86.8%), including complete pain relief in 57 (53.8%). The extension deficit was normalized in 68 of 83 affected knees (81.9%). Lachman and anterior drawer tests showed a firm endpoint in all, and 85.8% showed good to excellent subjective satisfaction.

CONCLUSIONS

Mucoid hypertrophy of the ACL should be suspected in elderly women presenting pain on terminal extension without preceding trauma, especially when associated with extension deficit. The magnetic resonance imaging findings are specific for preoperative diagnoses. Partial ACL debridement with notchplasty provides safe and effective symptom relief. Extension pain improved significantly in 92 of 106 knees (86.8%), and extension deficit was normalized in 68 of 83 knees (81.9%).

Arthroscopic decompression and notchplasty for long-standing anterior cruciate ligament impingement in a patient with multiple epiphyseal dysplasia: a case report

INTRODUCTION

Multiple epiphyseal dysplasia is a genetically and clinically heterogeneous osteochondroplasia with symmetrical involvement. It is characterized by joint pain in childhood and early adulthood with early onset of osteoarthritis, mainly affecting the hips.

CASE PRESENTATION

We report the case of a 20-year-old man of Asian origin with multiple epiphyseal dysplasia presenting with bilateral knee pain, stiffness and instability found to be caused by bilateral anterior cruciate ligament impingement on abnormal medial femoral condyles. Bilateral staged arthroscopic notchplasty was performed successfully, resulting in subjective relief of pain, and improved range of movement and stability.

CONCLUSION

Care should be taken not to exclude a diagnosis of multiple epiphyseal dysplasia when few of the characteristic radiographic features are evident but clinical suspicion is high. This case highlights the scope for subjective symptomatic improvement following a minimum of surgical intervention. We recommend limiting early intervention to managing symptomatic features rather than radiographic abnormalities alone.