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Emre TY, Cetin H, Selcuk H, Kilic KK, Aykanat F, Sarikcioglu L, Kose O. Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint. Arch Orthop Trauma Surg 2024; 144:1675-1684. [PMID: 38400901 PMCID: PMC10965741 DOI: 10.1007/s00402-024-05213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/24/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE Level IV, cadaveric study.
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Affiliation(s)
- Tuluhan Yunus Emre
- Department of Orthopaedics and Traumatology, Kadikoy Hospital, Acıbadem University, Istanbul, Turkey
| | - Hakan Cetin
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Koray Kaya Kilic
- Department of Radiology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Faruk Aykanat
- Medical Faculty Department of Orthopaedics and Traumatology, Sanko University, Gaziantep, Turkey
| | - Levent Sarikcioglu
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey.
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey.
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Qi H, Li Z, Ma T, Ren C, Xu Y, Huang Q, Zhang K, Li M. Treatment of proximal patellar tendon rupture with custom-made anchor-like plate and suture: cases report and literature review. Front Surg 2023; 10:1170760. [PMID: 37228760 PMCID: PMC10203210 DOI: 10.3389/fsurg.2023.1170760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
We reported 2 cases of patellar tendon rupture at the lower pole of the patella. For patellar tendon rupture, simple suture fixation has been proved to be inadequate in strength. Our center uses custom-made anchor-like plate and suture to treat proximal patellar fracture. The fixation strength is reliable, no additional bone tunnel is required, and the fixation of the lower patellar fracture can be achieved at the same time. After the operation, the patient starts functional exercise of the knee joint at an early stage, The function of the knee joint of the patient recovered well after 1 year, without other complications.
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Affiliation(s)
- Hongfei Qi
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Cheng Ren
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Yibo Xu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Ming Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
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Dong Z, Xu C, Yan L, Liu J, Wang F. Isolated medial patellofemoral ligament reconstruction is valid to stabilize patellofemoral joint but uncertain to reduce patellar height in setting of lateral patellar dislocation and patella alta. Arch Orthop Trauma Surg 2023; 143:1505-1512. [PMID: 35362817 DOI: 10.1007/s00402-022-04429-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 03/20/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Medial patellofemoral ligament reconstruction (MPFLR) is the most commonly used surgical treatment for patients with lateral patellar dislocation (LPD). It is still poorly understood whether or not MPFLR has a contributory effect on decreasing patellar height. MATERIALS AND METHODS Forty-five patients who underwent isolated MPFLR for LPD and patella alta were evaluated with a mean follow-up period of 24 months (22-25 months). Knee joint functions were evaluated by Banff patellofemoral instability instrument (BPII) 2.0 scores and Kujala scores. Patellofemoral engagement and stability were assessed by the patella tilt angle (PTA) and patellar congruence angle (PCA) measured by CT scans, and the patellar-glide test. Patellar height was calculated on lateral radiographs according to three methods: Caton-Deschamps ratios (CDR), Insall-Salvati ratios (ISR), and Blackburne-Peel ratios (BPR). A threshold value of p < 0.05 denoted a statistically significant difference. RESULTS Significant improvements were found in both BPII 2.0 scores, which increased from 41.7 to 77.8 (p < 0.001) and Kujala scores, which increased from 49.2 to 85.5 (p < 0.001). Post-operative PTAs and PCA decreased from 19.6 ± 8.8 to - 3.4 ± 6.2, and from 24.6 ± 7.3 to 13.1 ± 3.8 degrees respectively (p < 0.001). No patients showed lateral translation more than grade II in the patellar-glide test. Regarding patellar height, a tiny reduction (Δ = 0.02, Δ max = 0.09) was discovered in using CDR (p = 0.027), rather than ISR or BPR. All measurements of radiographic indices had an excellent intra- and inter-rater reliability (ICC > 0.75). CONCLUSIONS Isolated anatomic MPFLR is sufficient to achieve good clinical outcomes, as well as patellofemoral stability and high rates of return-to-sport. However, it is unclear if the reconstructed MPFL has a contributory effect on reducing patellar height.
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Affiliation(s)
- Zhenyue Dong
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Chenyue Xu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Lirong Yan
- Basic Medicine of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Junle Liu
- Basic Medicine of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
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Muacevic A, Adler JR. The Effect of Patellofemoral Maltracking and Patella Type on Symptomatic Bipartite Patella. Cureus 2023; 15:e34076. [PMID: 36843797 PMCID: PMC9946904 DOI: 10.7759/cureus.34076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Purpose The aim of this study is to investigate the relationship of trochlear dysplasia (TD) and patella type with bipartite patella (BP). Materials and methods A total of 5,081 knee MRIs taken in our institution were reviewed retrospectively. Patients with a history of knee surgery, previous or recent trauma, and rheumatologic involvement were excluded from the study. The MRIs of 49 patients with bipartite/multipartite patella were detected. Three patients were excluded: two patients had a tripartite variant, and one had multiple osseous dysplastic findings. Overall, 46 patients with BP were included in the study. BPs were classified as type I, II, and III. Patients were divided into symptomatic and asymptomatic groups according to the presence of edema within the bipartite fragment and adjacent patella. Patients were examined in terms of patella type, trochlear dysplasia, tuberosity-trochlear groove (TT-TG) difference, sulcus angle, and sulcus depth. Results There were 46 patients with BP (28 males and 18 females) (mean age: 33±9.5 years, range: 18-54). Thirty-eight bipartite fragments (82.6%) were type III and eight (17.4%) were type II. There was no type I BP. Seventeen (36.9%) were symptomatic, and 29 (63.1%) were asymptomatic. Seven of the type II (87.5%) and 10 of the type III (26.3%) bipartite fragments were symptomatic. The frequency and degree of trochlear dysplasia (p=0.007 and p=0.041, respectively) were found to be higher in symptomatic patients. The trochlear sulcus angle was higher (p=0.007) and the trochlear depth was lower (p=0.006) in the symptomatic group. No statistically significant difference was found (p=0.247) in terms of TT-TG difference. Type III and type IV patella were more common in the symptomatic group. Conclusion The current study shows that patellofemoral instability and patella type are associated with symptomatic BP. Patients with trochlear dysplasia, type II BP, and disproportionate patellar facet may have a significantly increased risk of symptomatic BP.
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Affiliation(s)
| | - John R Adler
- Radiology, Bagcilar Training and Research Hospital, Istanbul, TUR
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Magnussen RA, Peters NJ, Long J, Pappa N, Schmitt LC, Brunst CL, Kaeding CC, Flanigan DC. Accelerated rehabilitation program following medial patellofemoral ligament reconstruction does not increase risk of recurrent instability. Knee 2022; 38:178-183. [PMID: 36063612 DOI: 10.1016/j.knee.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/13/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rehabilitation protocols following medial patellofemoral ligament (MPFL) reconstruction were historically restrictive, with patients often immobilized and/or given weightbearing restrictions. However, more recently published protocols have been more aggressive. We compared patient-reported outcomes and recurrent dislocation risk between patients treated with a restrictive rehabilitation program (early post-operative bracing and weightbearing restrictions) and an accelerated rehabilitation protocol (no post-operative bracing or weightbearing restrictions) following MPFL reconstruction. METHODS Patients who underwent isolated MPFL reconstruction at an academic center between 2008 and 2016 were identified. Patient demographics, anatomical measurements, surgical details, and outcomes were collected. During this period, the rehabilitation protocol at the center transitioned from a restrictive to an accelerated rehabilitation protocol. Failure risk and patient-reported outcomes were compared based on rehabilitation protocol. RESULTS Of the163 isolated MPFL reconstructions performed during the study period, 123 (75%) were available for minimum one-year follow up at a mean of 4.0 years post-operative. Overall, 53 knees (43%) underwent the accelerated rehabilitation protocol and the remaining 70 knees (57%) underwent the restrictive protocol. There were 3 recurrent dislocations during the study period (2.4%), all of which occurred in the restrictive rehabilitation group. Multiple linear regression demonstrated that being in the accelerated rehabilitation group was not associated with poorer Knee injury and Osteoarthritis Outcome Score (KOOS) subscales controlling for age, sex, body mass index, Caton-Deschamps Index, tibial tubercle-trochlear groove distance, sulcus angle, MPFL graft choice, and length of follow-up. CONCLUSION An accelerated rehabilitation protocol without immobilization or weightbearing restrictions does not increase risk of recurrent patellar dislocation or poorer patient-reported outcome following isolated MPFL reconstruction.
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Affiliation(s)
- Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, United States.
| | - Nicholas J Peters
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Joseph Long
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Nicholas Pappa
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Laura C Schmitt
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Caroline L Brunst
- Sports Medicine Research Institute, The Ohio State University, United States
| | | | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, United States
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Biz C, Stecco C, Crimì A, Pirri C, Fosser M, Fede C, Fan C, Ruggieri P, De Caro R. Are Patellofemoral Ligaments and Retinacula Distinct Structures of the Knee Joint? An Anatomic, Histological and Magnetic Resonance Imaging Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031110. [PMID: 35162134 PMCID: PMC8834464 DOI: 10.3390/ijerph19031110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
There is disagreement regarding the description of the patellofemoral ligaments (PFLs), considered by some authors as capsular thickening and by others as independent ligaments. It was hypothesised that the PFLs and retinacula are structures with different histological features. The aim of this study was to describe the stabilising structures of the patella in detail and to determine if the PFLs and retinacula are different and separable structures from a macroscopic, microscopic and imaging viewpoint. An anatomical study was performed on eight knees from five cadavers (mean age, 56.2 years; range, 35–63 years), and a histological study was conducted on specimens from nine patients having a mean age of 65 years (range 35–84 years) who had undergone surgical knee procedures. The imaging study was based on 100 MRIs (96 patients). The mean age was 46 years (range 16–88), and the study analysed the capsular-ligamentous structures. In the medial compartment, the layers and structures were as follows: superficial layer, medial retinaculum; intermediate layer, Medial Collateral Ligament (MCL), Posterior Oblique Ligament (POL) and Medial Patellofemoral Ligament (MPFL); deep layer, deep part of the MCL and joint capsule. In the lateral compartment, the layers and structures were the following: superficial layer, lateral retinaculum; intermediate layer, Lateral Collateral Ligament (LCL) and Lateral Patellofemoral Ligament (LPFL); deep layer, joint capsule. All of the knees examined presented a clearly distinguishable MPFL and LPFL separable from the capsular layer. Histological study: there was a higher density of nerve fibres in retinacula compared to ligaments (p = 0.0034) and a higher content of elastic fibres in retinacula (p < 0.0005). In imaging, there was no difference between medial and lateral retinaculum thickness (p > 0.05). In conclusion, both the lateral and medial compartment can be described using the three-layer scheme. PFLs and retinacula are separate structures both macroscopically and according to imaging analysis. The retinacula respond to their specific function with a higher nerve fibre content and higher number of elastic fibres compared to the ligaments.
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Affiliation(s)
- Carlo Biz
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
- Correspondence: ; Tel.: +39-049-8213239
| | - Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Alberto Crimì
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Michele Fosser
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Caterina Fede
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Chenglei Fan
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Pietro Ruggieri
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Raffaele De Caro
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
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Zhang YQ, Zhang Z, Wu M, Zhou YD, Tao SL, Yang YL, Li Y, Liu JL, Li P, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A review. Medicine (Baltimore) 2022; 101:e28511. [PMID: 35029909 PMCID: PMC8735765 DOI: 10.1097/md.0000000000028511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Reconstruction of the medial patellofemoral ligament (MPFL) is an effective surgical method for the treatment of lateral patellar instability. At present, there is not much controversies regarding the femoral attachment, however, the controversies regarding patellar attachment versus attachment, number of graft strands, tension, isometry and so on. The following electronic databases will be searched: PubMed, the Cochrane Library, Embase, Web of Science, Medline. We will consider articles published between database initiation and March 2021. MPFL in the subject heading will be included in the study. Language is limited to English. Research selection, data extraction, and research quality assessment were independently completed by 2 researchers. CONCLUSIONS MPFL reconstruction is a reliable technique for the treatment of patellofemoral instability. The Schöttle point is still the mainstream method for locating the femoral attachment, the patellar attachment for single-bundle is located at the junction of the proximal one third and the distal two third of the longitudinal axis of the patella. For double-bundles, one is located in the proximal one third of the medial patellar edge and another is in the center of the patellar edge. Meanwhile, the adjustment of graft tension during operation is very important.
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Kharat S, Jaiswal S, Wankhade U, Gudhe M, Tarekar S, Bhakare A. Nonabsorbable transosseous sutures for lower pole patella fractures: An effective surgical technique to prevent implant complications. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2022. [DOI: 10.4103/jotr.jotr_96_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Dandu N, Trasolini NA, DeFroda SF, Darwish RY, Yanke AB. The Lateral Side: When and How to Release, Lengthen, and Reconstruct. Clin Sports Med 2021; 41:171-183. [PMID: 34782073 DOI: 10.1016/j.csm.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The lateral patellofemoral complex is an important stabilizer to medial and lateral displacement of the patella. Soft tissue abnormalities can range from pathologic tightness to laxity, presenting with symptoms related to patellar instability, anterior knee pain, or arthritis. Clinical evaluation should be performed to confirm patellar dislocation, assess the integrity of the lateral and medial soft tissues, and explore other pathoanatomic factors that may need to be addressed. Lateral retinacular lengthening is recommended over lateral release owing to the potential of iatrogenic medial instability with release, and a lateral patellofemoral ligament reconstruction can be performed to effectively treat medial instability.
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Affiliation(s)
- Navya Dandu
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Nicholas A Trasolini
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Steven F DeFroda
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Reem Y Darwish
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Adam B Yanke
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA.
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Abstract
Patellar instability is a broad term that encompasses patellar dislocation, patellar subluxation, and patellar instability. Although both functional and anatomic considerations contribute to symptoms of patellar instability, the most important are thought to be patella alta, trochlear dysplasia, and lateralization of the tibial tubercle. In patients with a history suspicious for prior patellar dislocation, careful evaluation of MRI and radiographic studies can reveal characteristic findings. The most common methods to address patellofemoral instability are medial patellofemoral ligament reconstruction and tibial tubercle osteotomy with either anteromedialization or medialization. Less commonly trochleoplasty is indicated as well. Patients may be treated with one of or a combination of these techniques, each of which has specific indications and complications.
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Affiliation(s)
- Erin McCrum
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA.
| | - Kyle Cooper
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke Health Heritage, Duke University School of Medicine, 3000 Rogers Road, Wake Forest, Durham, NC 27587, USA
| | - Robert J French
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
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Wang M, Li X, Li P, Wang H, Gao W. Modified Partial Lateral Facetectomy of the Patella for Stage III Patellofemoral Osteoarthritis with 5-Year Follow-Up. J Knee Surg 2021; 34:1142-1148. [PMID: 32659822 DOI: 10.1055/s-0040-1713899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The main aim of this article was to examine the therapeutic evaluation of our modified partial lateral facetectomy of the patella for stage III lateral patellofemoral osteoarthritis (PFOA), which includes (1) partial lateral patella articular facet that was resected; (2) coronal Z-shaped incision to lengthen lateral retinaculum; (3) patellar perimeter electrocoagulation to denervate. Between December 2008 and January 2013, 36 knees of 32 patients with severe patellofemoral (PF) osteoarthritis (OA) were treated with our modified partial patellar lateral facetectomy. All patients were stage III according to the Iwano scale, and their patellas were all Wiberg type III or Baumgartl type IV in shape. The study group included 6 males and 26 females with an average age of 54.03 years and an average disease course of 8.67 years. The modified Kujala scores were used to evaluate PF function, and the congruence angle was used to evaluate the patellar position. Knee Society Scores (KSS) were used to evaluate overall knee function. Six knees of five cases were lost to follow-up. Thirty knees of 27 cases were followed up for 5 years, with an average follow-up time of 60 ± 3.2 months. The average preoperative modified Kujala score was 15.93, and the average score at last follow-up was 32.03; The satisfactory PF function was achieved in 28 knees (93.33%). The congruence angle improved from preoperative +23. 07 degrees to 11. 91 degrees at the last follow-up. The average preoperative KSS were 110.40 points, which increased to 156.77 points at the last postoperative follow-up. Pain was significantly relieved, and the ability to climb stairs was significantly improved. All scores showed statistically significant improvements after surgery (p < 0.05). No complications were reported. Our modified partial lateral facetectomy of the patella for stage III lateral PFOA can relieve pain and partially improve function. This modified procedure is relatively simple, safe, and an effective treatment method for middle-aged and elderly patients with PFOA. Furthermore, this surgery can be used as an alternative or prephase to total knee arthroplasty. This is a Level IV, therapeutic study.
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Affiliation(s)
- Mingjun Wang
- Department of Gonarthrosis, Luoyang Orthopedic-Traumatological Hospital, Luoyang, Henan, China
| | - Xiaofeng Li
- Department of Bone Setting, Luoyang Orthopedic-Traumatological Hospital, Luoyang, Henan, China
| | - Peng Li
- Department of Gonarthrosis, Luoyang Orthopedic-Traumatological Hospital, Luoyang, Henan, China
| | - Hongyan Wang
- Department of Gonarthrosis, Luoyang Orthopedic-Traumatological Hospital, Luoyang, Henan, China
| | - Wenxiang Gao
- Department of Gonarthrosis, Luoyang Orthopedic-Traumatological Hospital, Luoyang, Henan, China
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Li Z, Liu G, Tian R, Kong N, Li Y, Li Y, Wang K, Yang P. The patellofemoral morphology and the normal predicted value of tibial tuberosity-trochlear groove distance in the Chinese population. BMC Musculoskelet Disord 2021; 22:575. [PMID: 34162383 PMCID: PMC8223279 DOI: 10.1186/s12891-021-04454-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background Our objective was to obtain normal patellofemoral measurements to analyse sex and individual differences. In addition, the absolute values and indices of tibial tuberosity-trochlear groove (TT-TG) distances are still controversial in clinical application. A better method to enable precise prediction is still needed. Methods Seventy-eight knees of 78 participants without knee pathologies were included in this cross-sectional study. A CT scan was conducted for all participants and three-dimensional knee models were constructed using Mimics and SolidWorks software. We measured and analysed 19 parameters including the TT-TG distance and dimensions and shapes of the patella, femur, tibia, and trochlea. LASSO regression was used to predict the normal TT-TG distances. Results The dimensional parameters, TT-TG distance, and femoral aspect ratio of the men were significantly larger than those of women (all p values < 0.05). However, after controlling for the bias from age, height, and weight, there were no significant differences in TT-TG distances and anterior-posterior dimensions between the sexes (all p values > 0.05). The Pearson correlation coefficients between the anterior femoral offset and other indexes were consistently below 0.3, indicating no relationship or a weak relationship. Similar results were observed for the sulcus angle and the Wiberg index. Using LASSO regression, we obtained four parameters to predict the TT-TG distance (R2 = 0.5612, p < 0.01) to achieve the optimal accuracy and convenience. Conclusions Normative data of patellofemoral morphology were provided for the Chinese population. The anterior-posterior dimensions of the women were thicker than those of men for the same medial-lateral dimensions. More attention should be paid to not only sex differences but also individual differences, especially the anterior condyle and trochlea. In addition, this study provided a new method to predict TT-TG distances accurately. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04454-8.
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Affiliation(s)
- Zhe Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Guanzhi Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Run Tian
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Ning Kong
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Yue Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Yiyang Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Kunzheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Pei Yang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China.
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Patel RM, Gombosh M, Polster J, Andrish J. Patellar Tendon Imbrication Is a Safe and Efficacious Technique to Shorten the Patellar Tendon in Patients With Patella Alta. Orthop J Sports Med 2020; 8:2325967120959318. [PMID: 33195712 PMCID: PMC7605011 DOI: 10.1177/2325967120959318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/11/2020] [Indexed: 01/17/2023] Open
Abstract
Background Patella alta has been noted to be a risk factor for recurrent patellar instability. Purpose We conducted a radiographic study to determine whether a patellar tendon imbrication technique normalizes patellar height as well as whether the shortened length is maintained at a minimum 2-year follow-up. Study Design Case series; Level of evidence, 4. Methods A total of 54 consecutive patients were identified after a retrospective chart review was performed on patients who underwent patellar tendon imbrication between 2008 and 2013. Preoperative, 3 weeks postoperative, and minimum 2 years postoperative lateral radiographs were analyzed using Insall-Salvati (IS), Blackburne-Peel (BP), and Caton-Deschamps (CD) indices to determine the amount of shortening that was achieved after the procedure and to what degree that shortening was maintained at a minimum 2-year follow-up. Results A total of 27 patients (32 knees) completed a minimum 2-year follow-up. The mean patellar tendon length preoperatively was 6.1 cm (range, 5-8 cm). At 3 weeks and 2 years, the mean tendon lengths were 5.1 and 5.2 cm, respectively. Thus, the mean ± SD change in patellar tendon length from preoperative to 3 weeks postoperative was 0.97 ± 0.67 cm. IS, BP, and CD ratios had minimal change (loss of correction) from 3-week to 2-year follow-up; the delta values were 0.04, -0.03, and 0.09, respectively. There were no complications directly related to the technique. Conclusion Patellar tendon imbrication is a safe and effective procedure to correct patella alta in the setting of lateral patellar instability. On average, the technique allowed 1 cm of patellar tendon shortening and maintained the correction at a minimum 2-year follow-up. In the skeletally immature patient, this technique allows correction of patella alta by avoidance of a tibial tuberosity osteotomy.
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Affiliation(s)
- Ronak M Patel
- Illinois Center for Orthopaedic Research and Education, Hinsdale Orthopaedic Associates, Westmont, Illinois, USA
| | - Michael Gombosh
- South Florida International Orthopaedics, Miami, Florida, USA
| | - Joshua Polster
- Sports Health, The Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
| | - Jack Andrish
- Sports Health, The Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
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Caterson J, Williams MA, McCarthy C, Athanasou N, Temple HT, Cosker T, Gibbons M. The articularis genu muscle and its relevance in oncological surgical margins. Bone Jt Open 2020; 1:585-593. [PMID: 33215156 PMCID: PMC7659671 DOI: 10.1302/2633-1462.19.bjo-2020-0113.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aims The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG. Methods In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)). Results AG was best visualized with T1-weighted axial images providing sufficient cover in 25 cases confirmed by pathological findings.These results demonstrate AG as a discrete and substantial muscle of the anterior compartment of the thigh, deep to VI and useful in providing anterior soft tissue margin in distal femoral resection in bone tumours. Conclusion Preoperative assessment of cover by AG may be useful in predicting cases where AG can be dissected, sparing the remaining quadriceps muscle, and therefore function. Cite this article: Bone Joint Open 2020;1-9:585–593.
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Affiliation(s)
| | | | - Catherine McCarthy
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Athanasou
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Thomas Temple
- Department of Orthopaedic Surgery, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Thomas Cosker
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Max Gibbons
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Maffulli N, Aicale R, D'Addona A, Young DA, Kader DF, Oliva F. Combined medial patellofemoral and patellotibial reconstruction with soft tissue fixation in recurrent patellar dislocation. Injury 2020; 51:1867-1873. [PMID: 32580890 DOI: 10.1016/j.injury.2020.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The medial patellofemoral and patellotibial ligaments (MPFL and MPTL) are the main passive restraints to lateral patellar translation. When nonoperative management of patellofemoral dislocations fails, surgical options can be considered to restore patellofemoral stability. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, quadriceps tendon, and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. MATERIALS AND METHODS Patients who suffered at least two documented episodes of unilateral patellar dislocation, confirmed radiographically and at clinical examination, underwent combined MPFL and MPTL reconstruction. Patients were regularly followed-up postoperatively at 2, 4, 8, 12, and 24 weeks, and then annually for a minimum of 2.5 years. Clinical and functional evaluations were performed using the modified Cincinnati rating system and the Kujala score, while anthropometry values including thigh volume and cross-sectional area of the thigh were measured before the operation and at the latest follow-up bilaterally. RESULTS There were 7 males and 27 females with a mean age of 26.5 ± 10.7 years (range, 13-39 years). The mean follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score Increased from 51 ± 22 preoperatively to 90 ± 19 (P = .001). The mean Kujala scores increased from 47 ± 17 preoperatively to 82 ± 17 (P = .02), with no significant differences between patients with or without osteochondral lesions (P ≥ .05), and between male and female patients (P ≥ .08). The Insall-Salvati index was 1.1 preoperatively and remained within normal range (P = .05) at the latest follow-up. CONCLUSION Combined reconstruction of MPFL and MPTL using an ipsilateral autologous gracilis tendon is satisfactory and effective and can be considered as suitable management option to treat recurrent dislocation of the patella. However, randomized studies are needed to compare different techniques. STUDY DESIGN Case series.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK; Keele University, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England, UK.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
| | - Alessio D'Addona
- Department of Public Health, Section of Orthopaedics and Trauma Surgery, A.O.U. Federico II School of Medicine, Surgery and Dentistry, "Federico II" University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - David A Young
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor VIC 3181, Australia
| | - Deiary F Kader
- Academic Unit, South West London Elective Orthopaedic Centre, Epsom, Surrey, UK
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
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Diermeier T, Tisherman R, Hughes J, Tulman M, Baum Coffey E, Fink C, Lynch A, Fu FH, Musahl V. Quadriceps tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2644-2656. [PMID: 32072203 DOI: 10.1007/s00167-020-05902-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022]
Abstract
Quadriceps tendon is a promising alternative graft option for anterior cruciate ligament (ACL) reconstruction, which can be harvested with or without a bone block as well as a full or partial thickness graft. Therefore, quadriceps tendon graft could be used in primary and revision ACL reconstruction based on the requirements (tunnel size, tunnel position, etc.). The all soft tissue, partial thickness quadriceps tendon graft in detail and pitfalls of the harvest are described in the present review. After quadriceps tendon harvest, especially in soccer players, who need a strong quadriceps to strike a ball with power, the postoperative rehabilitation may need to be adapted. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Rob Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Jonathan Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Michael Tulman
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopedic Sports Medicine and Injury Prevention, UMIT Hall, Hall, Austria
| | - Andrew Lynch
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.,UPMC Centers for Rehab Services, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.
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Luceri F, Roger J, Randelli PS, Lustig S, Servien E. How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height? Am J Sports Med 2020; 48:895-900. [PMID: 32058795 DOI: 10.1177/0363546520902132] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstruction of the medial patellofemoral ligament (MPFL) is the gold standard treatment for recurrent patellar dislocation. Patella alta has been reported in about half of patients with recurrent patellofemoral instability. HYPOTHESIS MPFL reconstruction (MPFLr) has a beneficial role in the correction of patellar height in patients with mild patella alta (Caton-Deschamps index [CDI] between 1.20 and 1.40). STUDY DESIGN Case series; Level of evidence, 4. METHODS Skeletally mature patients, with no history of previous or concomitant knee surgical procedures, who underwent isolated MPFLr using hamstring autograft for recurrent patellar instability between 2005 and 2018, were included in this study. The authors calculated CDI, modified Insall-Salvati index (MISI), and Blackburne-Peel index (BPI) ratios. Measurements done by 2 independent observers were calculated and used to compare pre- and postoperative patellar height (patella alta: CDI >1.20). RESULTS A total of 89 patients (95 knees) were included in the study, with a mean age of 25.0 years (range, 15.0-45.0 years). There were 70% women and 30% men. We found patella alta in 35.8% of cases preoperatively. Among them, 79.4% had reduced patellar height indices, within normal limits, postoperatively (mean follow-up, 18.4 ± 12.0 months). All the ratios showed a significant reduction in patellar height after surgery (CDI: 0.19 [range, -0.05, 0.60]; MISI: 0.22 [-0.14, 0.76]; BPI: 0.18 [-0.08, 0.59]; P < .00001). The CDI of 79.4% of the study knees was reduced to within normal limits postoperatively. The CDI was maintained within normal limits postoperatively in 93.4% of the knees with normal patellar height and reduced to normal in 50% of the knees with severe patella alta before surgery . No patient reported patella infera before surgery, whereas this condition was found in 8.2% of study patients postoperatively. A moderate correlation was reported between preoperative radiographic indices and their reduction after surgery (CDI: P < .001, ρ = 0.39; MISI: P < .001, ρ = 0.39; BPI: P < .001, ρ = 0.48). CONCLUSION The higher the preoperative patellar height, the more important is the lowering effect of MPFLr using the hamstring for patellar instability. Bony procedures should not be indicated in patients with patellar instability and a CDI between 1.20 and 1.40.
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Affiliation(s)
- Francesco Luceri
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,Università degli Studi di Milano, Milan, Italy
| | - Julien Roger
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France
| | - Pietro Simone Randelli
- UOC 1a Divisione, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy.,Laboratorio di Biomeccanica Applicata, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Sébastien Lustig
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,LBMC UMR T 9406, Laboratory of Chock Mechanics and Biomechanics, Claude Bernard Lyon 1 University, Lyon, France
| | - Elvire Servien
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,LIBM, EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
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19
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Lateral Patellofemoral Ligament Reconstruction: Anatomy, Biomechanics, Indications and Surgical Techniques. OPER TECHN SPORT MED 2019. [DOI: 10.1016/j.otsm.2019.150689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2426-2432. [PMID: 30374571 DOI: 10.1007/s00167-018-5226-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the most important ligamentous stabilizer preventing lateral patella dislocation. Numerous surgical procedures for MPFL reconstruction have been described in the literature. The aim of this study was to investigate the clinical, functional and patient-reported (PROM) outcomes 2 years after minimally invasive MPFL reconstruction performed using an autologous strip of the quadriceps tendon. METHODS Thirty-six patients (38 knees) were included in the study. For MPFL reconstruction, a partial thickness autologous quadriceps tendon graft was used. All patients were evaluated clinically and with patient-reported outcome questionnaires including the Tegner, Lysholm and Kujala scores as well as a visual analogue scale (VAS) for pain preoperatively and at 6, 12 and 24 months postoperatively. A functional Back-in-Action (BIA) test battery, including a total of seven stability, agility and jumping tests, was performed on 19 (50%) patients at the final follow-up. One patient was lost to follow-up at 24 months. RESULTS The mean age at the time of operation was 25.2 ± 6.1 years. No redislocations occurred during the period of investigation. The mean Lysholm score improved significantly from 79.3 ± 16.1 preoperatively to 83.2 ± 14.4 at 6 months, 88.1 ± 11.3 at 12 months and to 90.0 ± 9.6 at 24 months follow-up. No change throughout the study period was observed for the median Tegner Activity Score (median 6). The mean Kujala score increased from a preoperative value of 82.0 ± 12.4, to 84.5 ± 8.4 at 6 months, and 88.2 ± 5.8 at 12 months up to 88.7 ± 4.5 at 24 months follow-up. A total of 77.8% of the performed functional BIA tests were equal to or above the norm for patients of the corresponding ages and activity levels. CONCLUSIONS Minimally invasive MPFL reconstruction with a partial thickness strip of quadriceps tendon is a safe and effective treatment for patellofemoral instability. Good clinical, functional and subjective results were observed at the 2-year follow-up. LEVEL OF EVIDENCE Prospective cohort study, non-randomized, Level IV.
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Editorial Commentary: Medial Patellofemoral Complex: Driving a Better Understanding of Medial Knee Anatomy. Arthroscopy 2019; 35:1147-1151. [PMID: 30954108 DOI: 10.1016/j.arthro.2019.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 02/02/2023]
Abstract
Although its importance as the prime restraint to lateral patellar instability is undoubted, the anatomy of the medial patellofemoral ligament has never been agreed on. Since it was first described by Warren and Marshall in 1979, most of the anatomic studies confirmed its presence in 90% of the cases, but they usually provide inconsistent descriptions of its femoral and patellar attachments. It is proven that length changes in the reconstructed medial patellofemoral ligament depend principally on the femoral attachment site. Moreover, the femoral attachment site affects the patellar tilt, translation, and joint reaction force. Because of the early inconsistent descriptions of the medial patellofemoral ligament attachment sites, some authors have suggested that its anatomy is not fixed or may be patient specific.
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Osborne JD, Luczak SB, Acker WB, Bicos J. Patellofemoral Joint Contact Pressures: Current Concepts and Use in Patellar Instability Studies. Orthopedics 2019; 42:e172-e179. [PMID: 30668882 DOI: 10.3928/01477447-20190118-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/21/2018] [Indexed: 02/03/2023]
Abstract
The patellofemoral joint is thought to be a common source for knee pain. Improper alignment and function of the patellofemoral joint can lead to abnormal contact pressures, which may explain patients' symptoms. In this review, the authors examine techniques for measuring patellofemoral joint contact pressures and summarize the relevant patellofemoral joint anatomy and contact pressures in normal knee kinematics. Finally, they discuss the results of studies investigating contact pressure changes in cases of patellar instability. This includes both reconstruction of the medial patellofemoral ligament and tibial tubercle osteotomy. [Orthopedics. 2019; 42(2):e172-e179.].
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Castanov V, Hassan SA, Shakeri S, Vienneau M, Zabjek K, Richardson D, McKee NH, Agur AMR. Muscle architecture of vastus medialis obliquus and longus and its functional implications: A three‐dimensional investigation. Clin Anat 2019; 32:515-523. [DOI: 10.1002/ca.23344] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Valera Castanov
- Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Syed Ahmed Hassan
- Rehabilitation Sciences Institute, University of Toronto Toronto Ontario Canada
| | - Shayan Shakeri
- Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Maxine Vienneau
- Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Karl Zabjek
- Department of Physical TherapyUniversity of Toronto Toronto Ontario Canada
| | - Denyse Richardson
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Ontario Canada
| | - Nancy H. McKee
- Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Anne M. R. Agur
- Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
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DeFroda SF, Shah KN, Lemme N, Koruprolu S, Ware KJ, Owens BD. Biomechanical Properties of the Lateral Patellofemoral Ligament: A Cadaveric Analysis. Orthopedics 2018; 41:e797-e801. [PMID: 30222791 DOI: 10.3928/01477447-20180912-04] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/22/2018] [Indexed: 02/03/2023]
Abstract
Medial instability of the patellofemoral joint is a rare but known phenomenon; it may result from an incompetent lateral patellofemoral ligament (LPFL). However, biomechanical details of the ligament have not been the subject of scrutiny. The purpose of this study was to describe the biomechanical properties of the LPFL. Ten fresh-frozen human cadaveric knees were dissected to identify the LPFL. The ligament was harvested with a bone plug from the patella and the femoral surface and underwent axial loading to failure. Load to failure and location of failure were recorded. Regression analysis was performed to determine which anatomic variables (midsubstance width, femoral insertion width, patellar insertion width, or percent patellar articular surface of insertion) significantly influenced load to failure. Nine of the 10 specimens failed at the midsubstance of the ligament. The mean load to failure was 90±67 N. Logistical regression showed that midsubstance width was most correlated with load to failure, which approached but did not reach significance (P=.09). Studies are warranted to investigate the clinical consequences of medial patellar instability and the best repair or reconstruction techniques available. [Orthopedics. 2018; 41(2):e797-e801.].
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Patellar Dislocations: Review of Current Literature and Return to Play Potential. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0187-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Heales LJ, Badya R, Ziegenfuss B, Hug F, Coombes JS, van den Hoorn W, Tucker K, Coombes BK. Shear-wave velocity of the patellar tendon and quadriceps muscle is increased immediately after maximal eccentric exercise. Eur J Appl Physiol 2018; 118:1715-1724. [DOI: 10.1007/s00421-018-3903-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/25/2018] [Indexed: 10/14/2022]
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Grimm NL, Lazarides AL, Amendola A. Tibial Tubercle Osteotomies: a Review of a Treatment for Recurrent Patellar Instability. Curr Rev Musculoskelet Med 2018; 11:266-271. [PMID: 29721692 DOI: 10.1007/s12178-018-9482-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an overview of current surgical treatment options for tibial tubercle osteotomies as a treatment for recurrent patellofemoral instability. As such we sought to provide the reader with the most current answers to why treatment practices have changed and how this has affected the outcome of surgical treatment for patellar instability. RECENT FINDINGS As our understanding of patellofemoral biomechanics have grown, appropriate surgical and non-surgical treatment options have followed suit to address these findings. A clear understanding of the pathomechanics causing the patient's patellar instability is germane to choosing the most appropriate surgical intervention to address this instability. Likewise, understanding the goal of the intervention chosen-e.g., unloading, realignment-is paramount. These surgical techniques may be technically challenging and surgical specialists with experience in these techniques are recommended for optimal outcomes.
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Affiliation(s)
- Nathan L Grimm
- Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27705, USA.
| | - Alexander L Lazarides
- Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27705, USA
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27705, USA
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Abstract
PURPOSE Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction. RECENT FINDINGS Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.
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The interaction between the vastus medialis and vastus intermedius and its influence on the extensor apparatus of the knee joint. Knee Surg Sports Traumatol Arthrosc 2018; 26:727-738. [PMID: 28124107 DOI: 10.1007/s00167-016-4396-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Although the vastus medialis (VM) is closely associated with the vastus intermedius (VI), there is a lack of data regarding their functional relationship. The purpose of this study was to investigate the anatomical interaction between the VM and VI with regard to their origins, insertions, innervation and function within the extensor apparatus of the knee joint. METHODS Eighteen human cadaveric lower limbs were investigated using macro-dissection techniques. Six limbs were cut transversely in the middle third of the thigh. The mode of origin, insertion and nerve supply of the extensor apparatus of the knee joint were studied. The architecture of the VM and VI was examined in detail, as was their anatomical interaction and connective tissue linkage to the adjacent anatomical structures. RESULTS The VM originated medially from a broad hammock-like structure. The attachment site of the VM always spanned over a long distance between: (1) patella, (2) rectus femoris tendon and (3) aponeurosis of the VI, with the insertion into the VI being the largest. VM units were inserted twice-once on the anterior and once on the posterior side of the VI. The VI consists of a complex multi-layered structure. The layers of the medial VI aponeurosis fused with the aponeuroses of the tensor vastus intermedius and vastus lateralis. Together, they form the two-layered intermediate layer of the quadriceps tendon. The VM and medial parts of the VI were innervated by the same medial division of the femoral nerve. CONCLUSION The VM consists of multiple muscle units inserting into the entire VI. Together, they build a potential functional muscular complex. Therefore, the VM acts as an indirect extensor of the knee joint regulating and adjusting the length of the extensor apparatus throughout the entire range of motion. It is of clinical importance that, besides the VM, substantial parts of the VI directly contribute to the medial pull on the patella and help to maintain medial tracking of the patella during knee extension. The interaction between the VM and VI, with responsibility for the extension of the knee joint and influence on the patellofemoral function, leads readily to an understanding of common clinical problems found at the knee joint as it attempts to meet contradictory demands for both mobility and stability. Surgery or trauma in the anteromedial aspect of the quadriceps muscle group might alter a delicate interplay between the VM and VI. This would affect the extensor apparatus as a whole.
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Shah KN, DeFroda SF, Ware JK, Koruprolu SC, Owens BD. Lateral Patellofemoral Ligament: An Anatomic Study. Orthop J Sports Med 2017; 5:2325967117741439. [PMID: 29230426 PMCID: PMC5718311 DOI: 10.1177/2325967117741439] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Medial instability of the patellofemoral joint is a rare but known phenomenon that may result from an incompetent lateral patellofemoral ligament (LPFL). Surgical reconstruction of the LPFL has been described. However, anatomic details of the ligament have not been the subject of scrutiny. Purpose To describe the anatomic origin and insertion of the LPFL. Study Design Descriptive laboratory study. Methods Ten fresh-frozen, unpaired human cadaveric knees (mean age, 57 years) were dissected to identify the LPFL. The dissection was carried out by elevating the iliotibial band to expose the deep capsular layer of the knee joint, followed by a medial parapatellar approach to the knee. Then the quadriceps and patellar tendons were sectioned, and the LPFL was isolated by visualization and palpation. The LPFL was dissected to reveal its origin and insertion; these were measured with respect to the lateral epicondyle and the superior-inferior axis of the lateral patella, respectively. Results On average, the LPFL had a variable point of origin in location as well as width about the lateral epicondyle. The LPFL originated, on average, 2.6 mm distal (range, 13.1 mm proximal to 11.4 mm distal) and 10.8 mm anterior (range, 7.3 mm posterior to 14.9 mm anterior) to the lateral epicondyle. The LPFL insertion on the patella was more reliably found to be about 45% (range, 23.7%-58.4%) of its lateral articular surface. The insertion on the patella was found to be in the middle third of the lateral patella. Conclusion The LPFL has an origin that is variable but, on average, was found to be distal and anterior to the lateral epicondyle. The patella insertion was more reliably found to be in the middle third of the lateral patella. These anatomic relationships can help the surgeon reconstruct the LPFL in a more anatomic fashion. Clinical Relevance Surgeons who are tasked with reconstruction of the LPFL of a patient with idiopathic medial instability or a previous aggressive lateral release of the knee may reference this article to perform an anatomic reconstruction of the LPFL. We hope that having anatomic landmarks for the reconstruction of this ligament permits the surgeon to operate in an efficient manner that allows for the optimal outcome. This is a rare surgical issue, and no studies are available that provide this information. The little information present in the literature does not provide measurements for anatomic reconstruction; rather, it is limited to descriptions of reconstruction techniques that indirectly provide stability on the lateral aspect of the knee.
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Affiliation(s)
- Kalpit N Shah
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - James Kristopher Ware
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sarath C Koruprolu
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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Grob K, Gilbey H, Manestar M, Ackland T, Kuster MS. The Anatomy of the Articularis Genus Muscle and Its Relation to the Extensor Apparatus of the Knee. JB JS Open Access 2017; 2:e0034. [PMID: 30229230 PMCID: PMC6133144 DOI: 10.2106/jbjs.oa.17.00034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: The anatomy of the articularis genus muscle has prompted speculation that it elevates the suprapatellar bursa during extension of the knee joint. However, its architectural parameters indicate that this muscle is not capable of generating enough force to fulfill this function. The purpose of the present study was to investigate the anatomy of the articularis genus, with special emphasis on its relationship with the adjacent vastus intermedius and vastus medialis muscles. Methods: The articularis genus muscle was investigated in 18 human cadaveric lower limbs with use of macrodissection techniques. All components of the quadriceps muscle group were traced from origin to insertion, and their affiliations were determined. Six limbs were cut transversely in the middle third of the thigh. The modes of origin and insertion of the articularis genus, its nerve supply, and its connections with the vastus intermedius and vastus medialis were studied. Results: The muscle bundles of the articularis genus were organized into 3 main layers: superficial, intermediate, and deep. The bundles of the superficial layer and, in 60% of the specimens, the bundles of the intermediate layer originated from both the vastus intermedius and the anterior and anterolateral surfaces of the femur. The bundles of the deep layer and, in 40% of the specimens, the bundles of the intermediate layer arose solely from the anterior surface of the femur. The distal insertion sites included different levels of the suprapatellar bursa and the joint capsule. A number of connections between the articularis genus and the vastus intermedius were found. While the vastus medialis inserted into the whole length of the vastus intermedius aponeurosis, it included muscle fibers of the articularis genus, building an intricate muscle system supplied by nerve branches of the same medial deep division of the femoral nerve. Conclusions: The articularis genus, vastus medialis, and vastus intermedius have a complex, interacting architecture, suggesting that the articularis genus most likely does not act as an independent muscle. With support of the vastus intermedius and vastus medialis, the articularis genus might be able to function as a retractor of the suprapatellar bursa. The finding of likely interplay between the articularis genus, vastus intermedius, and vastus medialis is supported by their concurrent innervation. Clinical Relevance: The association between the articularis genus, vastus medialis, and vastus intermedius may be more complex than previously believed, and this close anatomical connection could have functional implications for knee surgery. Dysfunction, scarring, or postoperative arthrofibrosis of the sophisticated interactive mechanism needs further investigation.
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Affiliation(s)
- Karl Grob
- Department of Orthopaedic Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Helen Gilbey
- Hollywood Functional Rehabilitation Clinic, Perth, Western Australia, Australia
| | - Mirjana Manestar
- Department of Anatomy, University of Zürich-Irchel, Zürich, Switzerland
| | - Timothy Ackland
- The University of Western Australia, Perth, Western Australia, Australia
| | - Markus S Kuster
- The University of Western Australia, Perth, Western Australia, Australia
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Abstract
There is a consensus that there is no overt anterior joint capsule in the knee. However, other anterior structures act in lieu of a joint capsule: the quadriceps tendon and patellar retinacular fibres. In the absence of a capsule, the synovium forms the suprapatellar pouch. Other synovial structures, the plicae, are more controversial. They are often described as embryonic remnants with no function, despite surrounding the patella. We aimed to identify plical anatomy and histology on cadaveric dissection and to examine their embryology using the human virtual embryo website. Plicae were identified by two independent observers. Plical histology was examined using a panel of stains: H&E, Ab H&E, EVG and MSB trichrome. Embryonic knees were examined from Carnegie stages 20-23. Each knee had a suprapatellar plica and mediopatellar plica (MPP). The lateropatellar plica (LPP) appeared as a band in 5/10 cadavers, and as a ridge in the remainder. The overall impression, consistent across all specimens, was that the plicae formed a continuous band of synovial tissue around the proximal three-quarters of the patella. The infrapatellar fat pad (IFP) surrounded the remainder. Histologically, the plicae and IFP consisted of three layers (in order): a synovial layer, an undulated collagenous layer, and an adipose or areoloadipose layer. The subsynovial collagenisation is normally associated with the synovio-capsular boundary. Embryologically, plicae were not seen in either knee at any level for any given Carnegie stage. We suggest that plicae, along with the dynamic IFP, provide internal support to the patella mirroring the external support of retinacular fibres. Thus, the plicae complete the tissue complex acting in lieu of an anterior joint capsule. Evidence of plical functionality lends credence to the theory that the plicae are anatomical structures not functionless embryonic remnants.
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Affiliation(s)
| | - Michelle Spear
- Centre for Learning Anatomical SciencesUniversity of BristolBristolUK
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Kikuchi S, Tajima G, Yan J, Kamei Y, Maruyama M, Sugawara A, Fujino K, Takeda S, Doita M. Morphology of insertion sites on patellar side of medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2017; 25:2488-2493. [PMID: 26744281 DOI: 10.1007/s00167-015-3973-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/22/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to clarify the insertion sites on the patellar side of the medial patellofemoral ligament (MPFL). METHODS A total of 35 nonpaired human cadaveric knees were used in this study. After identification of the MPFL, the insertion sites on the patellar side of the MPFL were marked. Three-dimensional images were created, and the location and morphology of these insertion sites were analysed. RESULTS The morphology of the insertion sites on the patellar side of the MPFL was consistent. The proximal fibres of the MPFL were inserted to the deep fascia of the vastus medialis obliquus (VMO) and medial margin of the vastus intermedius (VI). The distal fibres of the MPFL were inserted to the medial margin of the patella directly. The insertion lengths of the VMO, VI, and patella were 26.7 ± 5.0, 28.5 ± 4.4, and 18.5 ± 4.4 mm, respectively. The rate of the vertical distance from the superior pole of the patella to the superior edge of the MPFL in relation to the total patellar height was 12 ± 4.4 %. At the distal edge, the rate was 58 ± 9.6 %. CONCLUSION The insertion sites on the patellar side of the MPFL were consistent. The MPFL inserted into the VMO and VI was significantly longer than into the patella. The clinical relevance of this study is to improve understanding of the anatomy of the insertion sites on the patellar side of the MPFL and the pathophysiology of patellar dislocation.
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Affiliation(s)
- Shuhei Kikuchi
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Goro Tajima
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan.
| | - Jun Yan
- Department of Anatomy, Iwate Medical University, Morioka, Japan
| | - Youichi Kamei
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Moritaka Maruyama
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Atsushi Sugawara
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Kotaro Fujino
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Sanjuro Takeda
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Minoru Doita
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
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An anatomic study of the lateral patellofemoral ligament. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:73-76. [PMID: 27516002 PMCID: PMC6197417 DOI: 10.1016/j.aott.2016.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/15/2016] [Accepted: 07/24/2016] [Indexed: 01/26/2023]
Abstract
Objective The lateral patellofemoral ligament (LPFL) is part of the lateral retinaculum cut during arthroscopic or open release. We investigated its anatomic and morphometric characteristics. Materials and methods We identified the LPFL insertion point on the condyle in vertical and sagittal planes in 32 adult cadaveric knees. We measured its length and width at the insertion point. We located the midpoint of this point and measured from it to the distal and posterior condylar ends. We measured anterior-posterior and proximal-distal lateral condylar lengths. We evaluated the insertion point shape on the lateral femoral condyle. Degree of relationship between variables was assessed using Pearson's correlation coefficient. p < 0.05 was considered statistically significant. Results The LPFL mean length was 23.2 mm, and mean width at the insertion point was 15.6 mm. Regarding its insertion into the lateral condyle, central insertions were more frequent (vertical plane: 53.1% central and sagittal plane: 75% central). A significant positive correlation was evident between the LPFL length and width at the insertion point (p = 0.05). Thus, the LPFL length was proportional to its width at the insertion point. A significant positive correlation was found between the anterior-posterior condylar length and width of the LPFL at the insertion point (p = 0.017). Therefore, greater anterior-posterior condylar length equates to a larger area of insertion on the condyle. Conclusion Greater width of the LPFL at the insertion point corresponds to greater LPFL and anterior-posterior lateral condylar lengths.
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Aframian A, Smith TO, Tennent TD, Cobb JP, Hing CB. Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc 2017; 25:3755-3772. [PMID: 27631645 PMCID: PMC5698363 DOI: 10.1007/s00167-016-4272-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 01/01/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the major medial soft-tissue stabiliser of the patella, originating from the medial femoral condyle and inserting onto the medial patella. The exact position reported in the literature varies. Understanding the true anatomical origin and insertion of the MPFL is critical to successful reconstruction. The purpose of this systematic review was to determine these locations. METHODS A systematic search of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and Cochrane Library) and unpublished literature databases was conducted from their inception to the 3 February 2016. All papers investigating the anatomy of the MPFL were eligible. Methodological quality was assessed using a modified CASP tool. A narrative analysis approach was adopted to synthesise the findings. RESULTS After screening and review of 2045 papers, a total of 67 studies investigating the relevant anatomy were included. From this, the origin appears to be from an area rather than (as previously reported) a single point on the medial femoral condyle. The weighted average length was 56 mm with an 'hourglass' shape, fanning out at both ligament ends. CONCLUSION The MPFL is an hourglass-shaped structure running from a triangular space between the adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle and inserts onto the superomedial aspect of the patella. Awareness of anatomy is critical for assessment, anatomical repair and successful surgical patellar stabilisation. LEVEL OF EVIDENCE Systematic review of anatomical dissections and imaging studies, Level IV.
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Affiliation(s)
- Arash Aframian
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK. .,St George's, University of London, London, SW17 0RE, UK. .,Imperial College, London, W6 8RP, UK.
| | - Toby O. Smith
- 0000 0001 1092 7967grid.8273.eFaculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
| | - T. Duncan Tennent
- grid.451349.eTrauma and Orthopaedics Department, 5th Floor St James’ Wing, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK ,grid.264200.2St George’s, University of London, London, SW17 0RE UK
| | | | - Caroline Blanca Hing
- grid.451349.eTrauma and Orthopaedics Department, 5th Floor St James’ Wing, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK ,grid.264200.2St George’s, University of London, London, SW17 0RE UK
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Elnikety S, Pendegrass CJ, de Godoy RF, Holden C, Blunn GW. Augmentation and repair of tendons using demineralised cortical bone. BMC Musculoskelet Disord 2016; 17:483. [PMID: 27855678 PMCID: PMC5114756 DOI: 10.1186/s12891-016-1323-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In severe injuries with loss of tendon substance a tendon graft or a synthetic substitute is usually used to restore functional length. This is usually associated with donor site morbidity, host tissue reactions and lack of remodelling of the synthetic substitutes, which may result in suboptimal outcome. A biocompatible graft with mechanical and structural properties that replicate those of normal tendon and ligament has so far not been identified. The use of demineralised bone for tendon reattachment onto bone has been shown to be effective in promoting the regeneration of a normal enthesis. Because of its properties, we proposed that Demineralised Cortical Bone (DCB) could be used in repair of a large tendon defect. METHODS Allogenic DCB grafts in strip form were prepared from sheep cortical bone by acid decalcification and used to replace the enthesis and distal 1 cm of the ovine patellar tendon adjacent to the tibial tuberosity. In 6 animals the DCB strip was used to bridge the gap between the resected end of the tendon and was attached with bone anchors. Force plate analysis was done for each animal preoperatively and at weeks 3, 9, and 12 post operatively. At week 12, after euthanasia x-rays were taken and range of movements were recorded for hind limbs of each animal. Patella, patellar tendon - DCB and proximal tibia were harvested as a block and pQCT scan was done prior to histological analysis. RESULTS Over time functional weight bearing significantly increased from 44% at 3 weeks post surgery to 79% at week 12. On retrieval none of the specimens showed any evidence of ossification of the DCB. Histological analysis proved formation of neo-enthesis with presence of fibrocartilage and mineralised fibrocartilage in all the specimens. DCB grafts contained host cells and showed evidence of vascularisation. Remodelling of the collagen leading to ligamentisation of the DCB was proved by the presence of crimp in the DCB graft on polarized microscopy. CONCLUSION Combined with the appropriate surgical techniques, DCB can be used to achieve early mobilization and regeneration of a tendon defect which may be applicable to the repair of chronic rotator cuff injury in humans.
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Affiliation(s)
- Sherif Elnikety
- John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculo-Skeletal Science, University College London, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - Catherine J Pendegrass
- John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculo-Skeletal Science, University College London, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - Roberta Ferro de Godoy
- John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculo-Skeletal Science, University College London, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - Charles Holden
- John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculo-Skeletal Science, University College London, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - Gordon W Blunn
- John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculo-Skeletal Science, University College London, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom.
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Gobbi RG, Pereira CAM, Sadigursky D, Demange MK, Tírico LEP, Pécora JR, Camanho GL. Evaluation of the isometry of different points of the patella and femur for medial patellofemoral ligament reconstruction. Clin Biomech (Bristol, Avon) 2016; 38:8-12. [PMID: 27521477 DOI: 10.1016/j.clinbiomech.2016.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/31/2016] [Accepted: 08/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The location of patellar and femoral fixation of the graft in medial patellofemoral ligament reconstructions has been widely discussed. This study aimed to assess the distances between different patellar and femoral fixation points to identify the least anisometric pairs of points. METHODS Ten cadaver knees were attached to an apparatus that simulated an active range of motion of 120°, with three metallic markers fixed onto the medial side of the patella, and seven markings onto the medial epicondyle. The examined points included the proximal patella pole (1), the patellar center (3), the midpoint between points 1 and 3 (2), a point directly on the epicondyle (6), points 5mm anterior (5) and posterior (7) to the epicondyle, points 5mm anterior to point 5 (4) and 5mm posterior to point 7 (8), and points 5mm proximal (9) and distal (10) to the epicondyle. The distances between patella and femur points were measured by a photogrammetry system at 15° intervals. FINDINGS The pair of points that exhibited the lowest average variability in distance, and hence was the most isometric, was the patella center combined with the anterior to the medial femoral epicondyle. The pairs of points that exhibited the highest average variability in distance, and hence were the least isometric, were the ones located distal or posterior to the medial femoral epicondyle, with less influence by the patellar location. INTERPRETATION Surgeons should avoid positioning the graft distally or posterior to the epicondyle due to the increase in anisometry.
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Khoshkhoo M, Killingback A, Robertson CJ, Adds PJ. The effect of exercise on vastus medialis oblique muscle architecture: An ultrasound investigation. Clin Anat 2016; 29:752-8. [PMID: 26940378 DOI: 10.1002/ca.22710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 02/28/2016] [Accepted: 02/28/2016] [Indexed: 11/09/2022]
Abstract
The vastus medialis oblique (VMO) is thought to be implicated in patellofemoral pain (PFP), and weakness in this portion of the vastus medialis muscle may lead to PFP. Management includes physiotherapy to strengthen the VMO. Although this intervention has been shown to be effective, the effects on the architecture of the muscle have not been investigated. This study aims to determine the changes in VMO architecture following a program of strengthening exercises. Twenty-one male participants underwent an initial ultrasound scan to measure the fiber angle and the insertion level of the VMO on the patella. Each subject then undertook a 6-week quadriceps femoris strengthening program; the scan and measurements were then repeated. A significant increase in VMO fiber angle and insertion length was observed. Average fiber angle increased by 5.24°; average insertion length increased by 2.7 mm. There was found to be a significant negative correlation between the initial values and the degree of change. Pearson's coefficient of correlation for measurements of patella length taken before and after exercise was 0.921, indicating a high degree of reliability. There was a significant positive correlation between fiber angle change and declared level of compliance (R(2) = 0.796). The results reported here indicate that physiotherapy leads to a significant change in VMO morphology. Given the inverse correlation noted between initial architectural parameters and the degree of change, we suggest that patients who would benefit most from physiotherapy can be identified in clinic using a simple ultrasound technique. Clin. Anat. 29:752-758, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- M Khoshkhoo
- Institute of Medical and Biomedical Education (Anatomy), St George's, University of London, London, United Kingdom
| | - A Killingback
- Department of Medical Physics and Clinical Engineering, St George's Healthcare NHS Trust, London, United Kingdom
| | - C J Robertson
- Wimbledon Clinics, Wimbledon, London, United Kingdom
| | - P J Adds
- Institute of Medical and Biomedical Education (Anatomy), St George's, University of London, London, United Kingdom
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Vaishya R, Vijay V, Demesugh DM, Agarwal AK. Surgical approaches for total knee arthroplasty. J Clin Orthop Trauma 2016; 7:71-9. [PMID: 27182142 PMCID: PMC4857169 DOI: 10.1016/j.jcot.2015.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/13/2015] [Indexed: 11/30/2022] Open
Abstract
There are various surgical approaches to the knee joint and its surrounding structures and such approaches are generally designed to allow the best access to an area of pathology whilst safeguarding important surrounding structures. Controversy currently surrounds the optimal surgical approach for total knee arthroplasty (TKA). The medial parapatellar arthrotomy, or anteromedial approach, has been the most used and has been regarded as the standard approach for exposure of the knee joint. It provides extensive exposure and is useful for open anterior cruciate ligament reconstruction, total knee replacement, and fixation of intra-articular fractures. Because this approach has been implicated in compromise of the patellar circulation, some authors have advocated the subvastus, midvastus, and trivector approaches for exposure of the knee joint. While these approaches expose the knee from the medial side, the anterolateral approach exposes the knee joint from the lateral side. With careful planning and arthrotomy selection, the anterior aspect of the joint can be adequately exposed for TKA in different clinical scenarios.
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Affiliation(s)
- Raju Vaishya
- Senior Consultant, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospital, New Delhi 110067, India,Corresponding author. Tel.: +91 9810123331.
| | - Vipul Vijay
- Consultant, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospital, New Delhi 110067, India
| | - Daniel Mue Demesugh
- Clinical Fellow, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospital, New Delhi 110067, India
| | - Amit Kumar Agarwal
- Consultant, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospital, New Delhi 110067, India
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Astur DC, Oliveira SG, Badra R, Arliani GG, Kaleka CC, Jalikjian W, Golanó P, Cohen M. UPDATING OF THE ANATOMY OF THE EXTENSOR MECHANISM OF THE KNEE USING A THREE-DIMENSIONAL VIEWING TECHNIQUE. Rev Bras Ortop 2015; 46:490-4. [PMID: 27027043 PMCID: PMC4799295 DOI: 10.1016/s2255-4971(15)30401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 08/25/2011] [Indexed: 01/13/2023] Open
Abstract
The knee extensor mechanism is a complex structure formed by the quadriceps muscle and tendon, the patella, the patellar tendon and the ligaments that surround and help stabilize the knee. Through using a three-dimensional viewing technique on images of the knee extensor apparatus, we aimed to didactically show the structures that compose this bone-muscle-ligament complex. Anatomical dissection of the knee with emphasis on the structures of its extensor mechanism was performed, followed by taking photographs using a camera and lenses suitable for simulating human vision, through a technique for constructing three-dimensional images. Then, with the aid of appropriate software, pairs of images of the same structure from different angles simulating human vision were overlain with the addition of polarizing layer, thereby completing the construction of an anaglyphic image. The main structures of the knee extensor mechanism could be observed with a three-dimensional effect. Among the main benefits relating to this technique, we can highlight that in addition to teaching and studying musculoskeletal anatomy, it has potential use in training for surgical procedures and production of images for diagnostic tests.
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Affiliation(s)
- Diego Costa Astur
- Orthopedist at the Sports Traumatology Center (CETE), Department of Orthopedics and Traumatology, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Ricardo Badra
- Orthopedist at the Cohen Institute, São Paulo, SP, Brazil
| | - Gustavo Gonçalves Arliani
- Orthopedist at the Sports Traumatology Center (CETE), Department of Orthopedics and Traumatology, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Camila Cohen Kaleka
- Orthopedist at the School of Medical Sciences, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Wahi Jalikjian
- Orthopedist at the School of Medicine of São José do Rio Preto, Ribeirão Preto, SP, Brazil
| | - Pau Golanó
- Anatomist at the University of Barcelona, Spain
| | - Moisés Cohen
- Full Professor in the Department of Orthopedics and Traumatology, and Head of the Sports Traumatology Department (CETE), UNIFESP, São Paulo, SP, Brazil
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Netto ADS, de Brito MBS, Severino FR, Campos LRA, Nico MAC, de Oliveira VM, Severino NR. STUDY ON THE PATELLOFEMORAL JOINT USING MAGNETIC RESONANCE IMAGING: MORPHOLOGICAL VARIATION OF THE MEDIAL PATELLOFEMORAL LIGAMENT. Rev Bras Ortop 2015; 47:204-9. [PMID: 27042622 PMCID: PMC4799380 DOI: 10.1016/s2255-4971(15)30087-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 09/22/2011] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To study the measurements and anatomical relationships of the patellofemoral joint using magnetic resonance imaging, and to evaluate the variation in the morphology of the medial patellofemoral ligament (MPFL) according to patients' heights and ages and the variation in measurements on other structures that are known to be involved in predisposition to patellar instability. METHOD Twenty-three knees (18 patients) underwent magnetic resonance imaging and their interepicondylar distance, patellar height, trochlear depth, ventral trochlear prominence, trochlear groove angle, lateral facet tilt, lateral patellar tilt and size of the lateral and medial facets and their ratio were measured. These measurements were compared with the length and thickness of the MPFL. RESULTS The average length of the MPFL was 46.4 mm, while the average thicknesses of its patellar insertion, middle third and femoral insertion were, respectively, 1.7 mm, 1.4 mm and 1.2 mm. The thickness of the MPFL correlated positively with the lateral condyle and interepicondylar distance measurements, and negatively with the patients' ages. CONCLUSION The morphology of the MPFL varies with the interepicondylar distance and the lateral condyle distance, and with patients' ages.
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Affiliation(s)
- Alfredo Dos Santos Netto
- Resident Physician in the Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Botelho Soares de Brito
- Resident Physician in the Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Fabrício Roberto Severino
- Trainee Physician in the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Leila Rodrigues Andrade Campos
- Resident Physician in the Musculoskeletal Radiology Group, Department of Imaging Diagnostics, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Astolfi Caetano Nico
- Attending Physician in the Musculoskeletal Radiology Group, Department of Imaging Diagnostics, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Victor Marques de Oliveira
- Attending Physician in the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Nilson Roberto Severino
- Physician and Head of the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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Criscenti G, De Maria C, Sebastiani E, Tei M, Placella G, Speziali A, Vozzi G, Cerulli G. Quasi-linear viscoelastic properties of the human medial patello-femoral ligament. J Biomech 2015; 48:4297-302. [PMID: 26573904 DOI: 10.1016/j.jbiomech.2015.10.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 10/23/2015] [Accepted: 10/26/2015] [Indexed: 11/26/2022]
Abstract
The evaluation of viscoelastic properties of human medial patello-femoral ligament is fundamental to understand its physiological function and contribution as stabilizer for the selection of the methods of repair and reconstruction and for the development of scaffolds with adequate mechanical properties. In this work, 12 human specimens were tested to evaluate the time- and history-dependent non linear viscoelastic properties of human medial patello-femoral ligament using the quasi-linear viscoelastic (QLV) theory formulated by Fung et al. (1972) and modified by Abramowitch and Woo (2004). The five constant of the QLV theory, used to describe the instantaneous elastic response and the reduced relaxation function on stress relaxation experiments, were successfully evaluated. It was found that the constant A was 1.21±0.96MPa and the dimensionless constant B was 26.03±4.16. The magnitude of viscous response, the constant C, was 0.11±0.02 and the initial and late relaxation time constants τ1 and τ2 were 6.32±1.76s and 903.47±504.73s respectively. The total stress relaxation was 32.7±4.7%. To validate our results, the obtained constants were used to evaluate peak stresses from a cyclic stress relaxation test on three different specimens. The theoretically predicted values fit the experimental ones demonstrating that the QLV theory could be used to evaluate the viscoelastic properties of the human medial patello-femoral ligament.
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Affiliation(s)
- G Criscenti
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy
| | - C De Maria
- Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy.
| | - E Sebastiani
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - M Tei
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - G Placella
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - A Speziali
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - G Vozzi
- Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy; Department of Ingegneria dell'Informazione, University of Pisa, via G. Caruso 16, 56126 Pisa, Italy
| | - G Cerulli
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
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Criscenti G, De Maria C, Sebastiani E, Tei M, Placella G, Speziali A, Vozzi G, Cerulli G. Material and structural tensile properties of the human medial patello-femoral ligament. J Mech Behav Biomed Mater 2015; 54:141-8. [PMID: 26454357 DOI: 10.1016/j.jmbbm.2015.09.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/09/2015] [Accepted: 09/23/2015] [Indexed: 11/13/2022]
Abstract
The medial patellofemoral ligament (MPFL) is considered the most important passive patellar stabilizer and acts 50-60% of the force of the medial soft-tissue which restrains the lateralization of the patella between 0° and 30°. In this work, 24 human knees have been tested to evaluate the material properties of MPFL and to determine the structural behavior of femur-MPFL-Patella complex (FMPC). Particular attention was given to maintain the anatomical orientation between the patella and MPFL and to the evaluation of the elongation during the mechanical tests. The ultimate stress of the isolated ligament was 16±11MPa, the ultimate strain was 24.3±6.8%, the Young׳s Modulus was 116±95MPa and the strain energy density was 2.97±1.69MPa. The ultimate load of the whole structure, FMPC, was 145±68N, the ultimate elongation was 9.5±2.9mm, the linear stiffness was 42.5±10.2N/mm and the absorbed energy was 818.8±440.7Nmm. The evaluation of material and structural properties of MPFL is fundamental to understand its contribution as stabilizer and for the selection of repair and reconstruction methods.
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Affiliation(s)
- G Criscenti
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy
| | - C De Maria
- Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy.
| | - E Sebastiani
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic Surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - M Tei
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic Surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - G Placella
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic Surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - A Speziali
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic Surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
| | - G Vozzi
- Research Center "E. Piaggio", University of Pisa, Largo Lucio Lazzarino 1, 56126 Pisa, Italy; Department of Ingegneria dell'Informazione, University of Pisa, via G. Caruso 16, 56126 Pisa, Italy
| | - G Cerulli
- Istituto di Ricerca Traslazionale per l׳Apparato Locomotore-Nicola Cerulli - LPMRI, via A. Einstein 12, 52100 Arezzo, Italy; Department of Orthopedic Surgery, University of Perugia, via S. Andrea delle Fratte 1, 06134 Perugia, Italy
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Isolated reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. J Orthop Traumatol 2015; 17:155-62. [PMID: 26387113 PMCID: PMC4882296 DOI: 10.1007/s10195-015-0375-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 08/28/2015] [Indexed: 12/03/2022] Open
Abstract
Background Since the role of the medial patellofemoral ligament (MPFL) as the primary soft-tissue restraint against lateral patellar translation has been recognized, several different reconstruction procedures for the treatment of patellar instability have been proposed over recent years. Many of these techniques require bony procedures and hardware fixation at the patellar and femoral side, leading to complications as described previously in the literature. The purpose of the present study is to describe the technique of isolated MPFL reconstruction using the quadriceps tendon and report the results at a mean follow-up of 38 months. The hypothesis is that this technique, not requiring drilling of bone tunnels on the patellar and femoral side, may be a "simple and safe" mean to manage patellar instability, giving good clinical results with low complication rate in selected patients with normal osseous anatomy. Materials and methods Sixteen consecutive patients (9 male, 7 female; mean age 22 years) with chronic patellar instability underwent medial patellofemoral reconstruction with the superficial layer of the quadriceps tendon. All the patients were evaluated preoperatively and postoperatively by physical examination and subjectively with Kujala and Lysholm scores. Results The average follow-up was 38 months (range 28–48 months). No recurrent episodes of dislocation or subluxation and no complications occurred. The mean Kujala score increased from 35.8 preoperatively to 88.8 postoperatively and the Lysholm score improved from 43.3 preoperatively to 89.3 postoperatively. Conclusions Isolated MPFL reconstruction using an autologous quadriceps tendon and not requiring bone tunnels, may be a safe, simple and effective procedure for the treatment of patellar instability without complications such as patellar fracture as reported by clinical studies using hamstring grafts. For the same reason it may also be indicated in skeletally immature patients. Level of evidence Level IV.
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Placella G, Tei M, Sebastiani E, Speziali A, Antinolfi P, Delcogliano M, Georgoulis A, Cerulli G. Anatomy of the Medial Patello-Femoral Ligament: a systematic review of the last 20 years literature. Musculoskelet Surg 2015; 99:93-103. [PMID: 24997630 DOI: 10.1007/s12306-014-0335-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 06/26/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Although many studies have investigated the anatomy of the Medial Patello-Femoral Ligament (MPFL), some studies have even questioned its existence. In the last 20 years, there is a renewed interest on the role of the MPFL in patello-femoral instability. As a result, several studies have been published that describe the anatomy, function and possible surgical reconstruction of the MPFL. Despite the large amount of literature produced, there is still a lack of consensus on what is its real anatomy as there are currently no systematic reviews on this topic. PURPOSES Thus, the aim of this review is to systematically report the results in literature regarding in anatomical papers, the existence, size, insertion sites and relationships of this ligament with the other medial structures of the knee. METHODS We have systematically analyzed anatomical studies currently available in literature between 1980 and December 2012. The search was carried out on Medline, Embase, Cochrane Library and Google Scholar. We checked reference lists of articles, reviews and textbooks identified by the search strategy for other possible relevant studies. RESULTS The outcomes examined are the presence of the ligament, its size (length, width, thickness), and its patellar and femoral insertions. A total of 312 cadaveric knees were included in the 17 studies; the MPFL was identified in 99% of cases (309). CONCLUSIONS The consensus is that the MPFL is almost always present in the dissected knees. The size and insertions of the ligament demonstrate great variation between cadavers. LEVEL OF EVIDENCE Systematic review of anatomical study, Level 1.
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Affiliation(s)
- G Placella
- Istituto di Ricerca Traslazionale per l'Apparato Locomotore - Nicola Cerulli - Let People Move RI, Via Pontani n° 9, 06100, Perugia, Italy,
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Lin KY, Lu YC, Renn JH. The double-pulley technique for anatomical double-bundled medial patellofemoral ligament reconstruction. Injury 2015; 46:1619-24. [PMID: 25916806 DOI: 10.1016/j.injury.2015.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Majority of the current medial patellofemoral ligament (MPFL) reconstruction techniques vary with respect to methods of fixation on the patella. In an effort to maximise the area of patellar footprint coverage and minimise the complication of patellar fracture, we developed a procedure that implemented the double-pulley suture anchors technique. DESIGN Prospective case series. SETTING A primary medical centre in Kaohsiung, Taiwan. PATIENTS AND METHODS Eighteen consecutive patients (18 knees) who met the inclusion criteria underwent the aforementioned operation between January 2010 and March 2012. Patients were evaluated using functional scores (Kujala and Tegner-Lysholm scores), apprehension test, and radiographic examination (congruence angle and patellar tilting angle) preoperatively and at the follow-up. RESULTS The mean follow-up was 35 months. A firm endpoint to lateral patellar translation was noted in all patients at the last follow-up with a mean lateral translation quadrant of 1.5 (improved from 3.5 preoperatively, p<0.001). Both clinical and radiographic assessment improved significantly (p<0.001); the mean Kujala score improved from 55.3±6.8 preoperatively to 95.2±3.5 at the last follow-up; TegnerLysholm from 43.6±8.1 to 93.6±6.8; the mean congruence angle improved from 20.6°±2.1° preoperatively to -5.2°±2.4° at the last follow-up; and the patellar tilting angle from 23.8°±2.3° to 9.6°±1.3°. CONCLUSION The double-pulley patellar fixation technique, by having a result that is comparable with those of other studies that used aperture fixation techniques, can be a promising surgical option for anatomically reconstructing the medial petellofemoral ligament.
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Affiliation(s)
- Kuan-Yu Lin
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Dazong 1(st) Road, Kaohsiung City, Taiwan.
| | - Yih-Chau Lu
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Dazong 1(st) Road, Kaohsiung City, Taiwan
| | - Jenn-Huei Renn
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Dazong 1(st) Road, Kaohsiung City, Taiwan
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Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015; 49:1277-83. [PMID: 25979840 DOI: 10.1136/bjsports-2014-094386] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Few interventions reduce patellar tendinopathy (PT) pain in the short term. Eccentric exercises are painful and have limited effectiveness during the competitive season. Isometric and isotonic muscle contractions may have an immediate effect on PT pain. METHODS This single-blinded, randomised cross-over study compared immediate and 45 min effects following a bout of isometric and isotonic muscle contractions. Outcome measures were PT pain during the single-leg decline squat (SLDS, 0-10), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition. Data were analysed using a split-plot in time-repeated measures analysis of variance (ANOVA). RESULTS 6 volleyball players with PT participated. Condition effects were detected with greater pain relief immediately from isometric contractions: isometric contractions reduced SLDS (mean±SD) from 7.0±2.04 to 0.17±0.41, and isotonic contractions reduced SLDS (mean±SD) from 6.33±2.80 to 3.75±3.28 (p<0.001). Isometric contractions released cortical inhibition (ratio mean±SD) from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition (pre 30.26±3.89, post 31.92±4.67; p=0.004). Condition by time analysis showed pain reduction was sustained at 45 min postisometric but not isotonic condition (p<0.001). The mean reduction in pain scores postisometric was 6.8/10 compared with 2.6/10 postisotonic. MVIC increased significantly following the isometric condition by 18.7±7.8%, and was significantly higher than baseline (p<0.001) and isotonic condition (p<0.001), and at 45 min (p<0.001). CONCLUSIONS A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms. Isometric contractions can be completed without pain for people with PT. The clinical implications are that isometric muscle contractions may be used to reduce pain in people with PT without a reduction in muscle strength.
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Affiliation(s)
- Ebonie Rio
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
| | - Dawson Kidgell
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Craig Purdam
- Department of Physical Therapies, Australian Institute of Sport, Bruce, Australian Capital Territory, Australia
| | - Jamie Gaida
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia University of Canberra, Canberra, Australian Capital Territory, Australia
| | - G Lorimer Moseley
- Sansom Institute for Health Research, University of South Australia & Pain Adelaide, Adelaide, South Australia, Australia
| | - Alan J Pearce
- Cognitive Neuroscience Unit, Deakin University, Burwood, Victoria, Australia
| | - Jill Cook
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
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Khormaee S, Kramer DE, Yen YM, Heyworth BE. Evaluation and management of patellar instability in pediatric and adolescent athletes. Sports Health 2015; 7:115-23. [PMID: 25984256 PMCID: PMC4332641 DOI: 10.1177/1941738114543073] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
CONTEXT The rising popularity and intensity of youth sports has increased the incidence of patellar dislocation. These sports-related injuries may be associated with significant morbidity in the pediatric population. Treatment requires understanding and attention to the unique challenges in the skeletally immature patient. EVIDENCE ACQUISITION PubMed searches spanning 1970-2013. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS Although nonoperative approaches are most often suitable for first-time patellar dislocations, surgical treatment is recommended for acute fixation of displaced osteochondral fractures sustained during primary instability and for patellar realignment in the setting of recurrent instability. While a variety of procedures can prevent recurrence, the risk of complications is not minimal. CONCLUSION Patellar stabilization and realignment procedures in skeletally immature patients with recurrent patellar dislocation can effectively treat patellar instability without untoward effects on growth if careful surgical planning incorporates protection of growth parameters in the skeletally immature athlete.
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Affiliation(s)
- Sariah Khormaee
- Harvard–MIT Health Sciences and Technology Program, Harvard Medical School, Boston, Massachusetts
| | - Dennis E. Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benton E. Heyworth
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy 2015; 31:541-54. [PMID: 25543249 DOI: 10.1016/j.arthro.2014.11.010] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/20/2014] [Accepted: 11/05/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity. METHODS We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised. RESULTS Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions. CONCLUSIONS Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.
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Abstract
Extensor mechanism disruption is a rare and potentially devastating complication associated with total knee arthroplasty. Disruption can occur at the quadriceps or patellar tendons or, in the setting of a fracture, at the patella. Recognition of the risk factors for disruption and prevention via meticulous surgical technique are critical to avoid this complication. Various management techniques and the challenges associated with treatment have been described. Nonsurgical management consists of the use of walking aids and/or knee braces, which may not be acceptable for the active patient. Surgical options include primary repair and reconstructive techniques using allograft, autograft, synthetic material, and gastrocnemius rotational flaps. However, no single method has reliably demonstrated satisfactory outcomes. Although research on reconstructive procedures with synthetic materials has been promising, further study is need to assess the use of these materials.
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