胫骨结节相对旋转度：一种新的评估髌股关节不稳的参数

目的 探讨胫骨结节相对旋转度（tibial tubercle-trochlear groove rotation angle,TTTGR）与髌股关节不稳的相关性,评估这一参数对于髌股关节不稳的诊断效力。方法 收集2020年1月至2020年12月于我科就诊的髌骨复发性脱位病人50例纳入脱位组,30例正常志愿者纳入对照组。四名观察者分别对两组病人的双膝关节CT影像进行分析,测量TTTGR、胫骨结节-滑车（tibial tubercle-trochlear groove,TT-TG）距离、滑车侧倾角（lateral trochlear inclination,LTI）、髌骨外倾角度（lateral patella tilt angle,LPTA）。评估各参数在观察者间的一致性,分析两组间上述参数的差异,TTTGR与其他参数的相关性,采用受试者工作特征（receiver operating characteristic,ROC）曲线分析各参数对于预测髌股关节不稳的灵敏度、特异度、阳性及阴性预测值。结果 脱位组的TTTGR、TT-TG、LPTA均显著高于对照组,LTI显著低于对照组,组间比较,差异有统计学意义（P＜0.05）。观察者间的一致性检验结果：TT-TG（ICC=0.975）、TTTGR（ICC=0.937）和LPTA（ICC=0.794）的组间一致性均为优秀,LTI（ICC=0.708）的组间一致性良好。TTTGR与TT-TG、LPTA呈正相关（r=0.544,r=0.476）,与LTI呈负相关（r=-0.430）。TT-TG对于髌股关节不稳的诊断准确性最高,约登指数：0.851,TTTGR诊断准确性次之（约登指数：0.733）,LTI则无诊断意义。其中,TTTGR的最佳截断值为34.6°,表现出敏感度为80.00%,特异度为93.30%;阳性预测值为92.27%,阴性预测值为82.34%。结论 TTTGR是可重复性高、可靠的髌股关节不稳评估指标,与TT-TG、LPTA等参数具有相关性,对于髌股关节不稳具有较高的诊断效力。     

EOSTM 3D影像系统诊断复发性髌骨脱位的可靠性和稳定性

目的 探讨EOS^TM 3D影像系统诊断复发性髌骨脱位的可靠性和稳定性。方法 回顾性分析2022年3月至2023年3月西安交通大学附属红会医院运动医学中心收治的22例（26膝）复发性髌骨脱位病人的影像学资料,两位影像学医生同时使用EOS^TM系统测量病人下肢力线,使用sterEOS软件对影像图片进行3D模型重建,并在三维模型中测量胫骨结节-股骨滑车沟（tibial tubercle-trochlear groove,TT-TG）间距,记录每次测量所需的时间和相关参数。所有病人同期进行常规膝关节CT扫描及三维重建。将EOS^TM 3D影像和CT扫描测量的TT-TG数值进行比较,采用一致性检验研究和Bland-Altman分析图评价测量结果数据的可靠性和稳定性。结果 进行EOS^TM下肢力线测量时,不同测量者间测量的股骨和胫骨长度、膝关节内外翻角度及股骨胫骨旋转角度之间差异无统计学意义（P＞0.05）。病人常规下肢CT扫描及三维重建测量时间为（21.8±3.2） min（13~29 min）,EOS^TM 3D测量时间为（6.3±1.8） min（4~11 min）,差异有统计学意义（t=12.693,P＜0.001）。两位医生使用EOS^TM 3D测量TT-TG值的组内相关系数为0.791,使用常规CT测量的组内相关系数为0.843,两种测量方法组内一致性均较好。Bland-Altman分析结果显示两位测量者分别有96.2%（25/26）、92.3%（24/26）的点位于±1.96标准差范围内,显示使用常规CT三维重建和EOS^TM 3D测量TT-TG值具备较好的一致性和稳定性。结论 使用EOS^TM 3D影像系统测量复发性髌骨脱位病人的TT-TG值,具有良好的可靠性及可重复性,具有检查时间短、辐射低等优势,是评估此类病人下肢力线数据的一种快捷、可靠及稳定的方法。     

中老年人胫骨结节-股骨滑车沟距离与髌股关节软骨退变之间的关系研究

目的：利用膝关节核磁共振成像（MRI）扫描探讨中老年人髌股关节软骨退变程度与胫骨结节-股骨滑车沟间距（TT-TG）之间的关系。方法：选取2020年9月—2022年12月在我院行膝关节MRI扫描的中老年患者515例。由两名从事骨科相关的影像科医生对髌股关节软骨退变分级进行客观评价。并利用GE工作站使用膝关节轴位图像后处理,进行TT-TG距离测量。比较髌骨侧软骨退变及股骨滑车侧软骨退变各组间TT-TG间距,采用Logistic回归分析TT-TG间距是否是关节软骨退变的影响因素,并绘制受试者特征曲线（ROC）进行分析。结果：髌骨侧软骨退变及股骨滑车侧软骨退变各组间TT-TG间距存在统计学意义（P <0.05）。髌骨侧关节软骨退变分级与TT-TG间距存在相关性（P=0.021）;股骨滑车侧关节软骨退变分级与TT-TG间距不存在相关性（P=0.737）。TT-TG间距对评估髌骨侧关节软骨退变存在诊断意义（AUC=0.583）,但诊断能力较低;而对股骨滑车侧关节软骨退变则不存在诊断意义（AUC=0.487）。结论：TT-TG间距对于髌骨侧关节软骨退变分级有一定的预测作用,但是无法准确预测股骨...     

髌腱外偏角的测量及在复发性髌骨脱位诊断中的应用

目的:比较髌腱外偏角和胫骨结节-滑车沟距离(tibia tubercle-trochlea groove,TT-TG)的CT测量结果,以及在复发性髌骨脱位中的诊断能力和病理阈值。方法:自2015年1月至2020年3月对46例复发性髌骨脱位患者和112例非髌骨脱位患者的病例资料进行回顾性分析。46例复发性髌骨脱位患者根据TT-TG值分为2组:TT-TG ≥ 20 mm髌骨脱位(A组)11例,男7例,女4例;年龄16~27(21.00±3.98)岁;TT-TG<20 mm髌骨脱位(B组)35例,男14例,女21例;年龄16~37(22.83±6.09)岁;非髌骨脱位(C组)112例,男63例,女49例;年龄16~36(22.87±5.69)岁。比较3组患者的髌腱外偏角和TT-TG值的测量数据,并采用Spearman分析其相关性。采用同类相关系数(intraclass correlation coefficient,ICC)确定组内的可重复性。利用受试者工作特征(receiver operating characteristic,ROC)曲线下面积评价参数的诊断能力,并计算出髌腱外偏角截骨参数,以及髌腱外偏角和TT-TG值在诊断复发性髌骨脱位的诊断参数。结果:A、B、C组的髌腱外偏角分别为(22.04±3.19)°、(17.20±4.43)°、(10.22±3.45)°,TT-TG值分别为(21.15±0.71)、(15.97±2.69)、(11.12±3.77) mm,3组比较差异有统计学意义(P<0.01),且A组与B组比较差异有统计学意义(P<0.01)。髌腱外偏角与TT-TG值对比,存在强正相关(r=0.735,P<0.000 1)。髌腱外偏角在A、B组中的组内ICC值(0.980、0.982)比TT-TG值(0.594、0.775)测量的可重复性更好,C组中髌腱外偏角(0.956)和TT-TG值(0.906)可重复性均很好。在复发性髌骨脱位诊断中,髌腱外偏角的ROC曲线下面积(0.916)大于TT-TG值(0.886),其诊断参数分别为13.84°和14.69 mm;在胫骨截骨术中,髌腱外偏角的ROC曲线下面积为0.821,截骨参数为20.15°。结论:CT成像可以可靠地测量髌腱外偏角。髌腱外偏角与TT-TG值存在强正相关,可通过其测量明确复发性髌脱位病理状态,并且髌腱外偏角在复发性髌骨脱位的诊断能力优于TT-TG值。髌腱外偏角同样可用于指导复发性髌骨脱位的胫骨截骨手术方案的制定。     

肩袖撕裂合并冻结肩行手法松解后的关节镜下表现及影响因素分析

目的 观察肩袖撕裂合并冻结肩行手法松解后的关节镜下表现,并分析其影响因素。方法 回顾性分析2017年9月至2019年9月收治的68例肩袖撕裂合并冻结肩病人的病例资料,其中,男35例,女33例,年龄为（52.68±6.54）岁,均行一期麻醉后手法松解联合关节镜检查并肩袖修复术,观察手法松解后的关节镜下表现,比较松解损伤病人和未损伤病人之间的性别、患侧、肩袖撕裂程度差异,分析患肩关节疼痛时间、肩关节活动受限病程和实施手法松解时间与手法松解损伤的相关性。收集病人的数字分级法（numerical rating scale, NRS）疼痛评分、美国肩肘外科医师学会（American Shoulder and Elbow Surgeons, ASES）评分、Constant-Murley评分及丹麦健康与医疗管理局（Danish Health and Medicine Authority）满意度评分。结果 共16例（23.53%）发生手法松解损伤,其中单一损伤者12例,两种及以上损伤者4例,损伤类型为前关节囊撕裂（3例,18.75%）、下关节囊撕裂（6例,37.50%）、盂肱中韧带撕裂（7例,43.75%）、盂肱下韧带肱骨端撕裂（humeral avulsion of the glenohumeral ligament, HAGL）（3例,18.75%）、前盂唇撕裂（2例,12.50%）。松解损伤病人和未损伤病人之间的年龄（P=0.431）、性别（P=0.893）、患侧（P=0.673）、肩袖撕裂程度（P=0.723）、患肩关节疼痛时间（P=0.813）、肩关节活动受限病程（P=0.250）、实施手法松解时间（P=0.125）均未见显著差异。松解损伤组和松解无损伤组术后NRS评分均较术前明显降低,肩关节功能评分较术前明显改善（P均＜0.05）;手术前后的NRS评分、肩关节功能ASES评分、Constant-Murley评分、病人满意度评分比较,差异均无统计学意义（P均＞0.05）。结论 肩袖撕裂合并冻结肩行麻醉后肩关节手法松解联合关节镜下肩袖修复术可能导致单一或合并的镜下损伤表现,年龄、性别、患侧、肩袖撕裂程度、患肩关节疼痛时间、肩关节活动受限病程、实施手法松解时间等因素与发生手法松解损伤无明确相关性。     

组配式假体在Crowe Ⅰ、Ⅱ型发育性髋关节发育不良全髋关节置换术中的应用

目的 探讨应用组配式假体行全髋关节置换术（total hip arthroplasty, THA）治疗CroweⅠ、Ⅱ型发育性髋关节发育不良（developmental dysplasia of the hip, DDH）的短期临床疗效。方法 回顾性分析2016年10月至2017年10月,中国人民解放军总医院骨关节科收治的40例单侧Crowe Ⅰ、Ⅱ型DDH病人的临床资料,其中男5例,女35例;年龄为（36.90±10.30）岁（19~51岁）,股骨选用组配式假体,全部纳入组配式假体组。另选择既往40例术前设计采用普通锥形假体的单侧Crowe Ⅰ、Ⅱ型DDH病人作为对照组。比较两组病人的基本信息,术中及术后并发症发生情况,术前及术后6个月髋关节Harris功能评分,术后双下肢长度及偏心距差异等指标。结果 组配式假体组与对照组病人的术中股骨假体周围骨折发生率（5.0%比10.8%）、术后脱位率（2.5%比8.1%）、偏心距差异发生率（20.0%比37.8%）比较,差异均无统计学意义（χ²=0.276,P=0.600;χ²=0.353,P=0.553;χ²=2.997,P=0.083）。术后,组配式假体组的髋关节Harris功能评分较对照组高[（89.45±9.22）分比（84.69±8.77）分;t=2.077,P=0.041],双下肢不等长发生率低（17.5%比43.2%;χ²=6.081,P=0.014）。结论 在Crowe Ⅰ、Ⅱ型DDH中,组配式假体比普通假体更易获得双下肢等长及更佳的关节功能。     

前十字韧带移植重建后移植物撞击新类型

 目的 通过双源CT三维重建前十字韧带（anterior cruciate ligament,ACL）移植重建后的移植物和骨隧道,分析移植物撞击症。方法 2012年11月至2014年11月,采用双源CT对134例ACL移植重建后患者的膝关节进行扫描,三维重建股骨和胫骨隧道、ACL重建移植物等。其中单束重建118例,男83例,女35例;年龄15~64岁,平均32岁。观察重建术后移植物是否受到撞击、撞击来源并进行分类;分别测量股骨、胫骨隧道的相对位置,并对有撞击与无撞击组患者进行统计比较。结果 基于双源CT移植物重建,根据ACL移植重建后移植物是否受到撞击分组,无撞击组39例（33%,39/118）,有撞击组79例（67%,79/118）。存在撞击者再根据撞击部位分为髁间窝出口撞击组77例（占总数的65%,占撞击组的97%）和髁间窝顶中途撞击组2例（占总数的2%,占撞击组的3%）。进一步根据撞击来源不同,再对髁间窝出口撞击组分为3个亚型,即鸟喙撞击10例（3%,10/77）、胫骨平台撞击46例（60%,46/77）、钳夹撞击21例（27%,21/77）。单因素方差分析显示,鸟喙撞击、胫骨平台撞击、钳夹撞击各组与无撞击组的股骨、胫骨隧道位置均无显著性差异。结论 基于双源CT三维重建ACL术后移植物扫描发现3种新的移植物撞击类型, 即髁间窝顶中途撞击、胫骨撞击和钳夹撞击。     

肩关节镜与非手术方法治疗夹层型肩袖撕裂的短期疗效比较

目的 对比关节镜手术与非手术治疗夹层型肩袖撕裂的短期临床效果。方法 前瞻性地纳入2013年1月至2018年1月我科门诊诊断为夹层型肩袖撕裂的51例病人,随机分为手术组（31例,使用关节镜下肩袖撕裂修复术治疗肩袖撕裂）及非手术组（20例,采用口服塞来昔布、外用非甾体类抗炎药物贴膏、功能康复锻炼及肌力锻炼的治疗方案）。治疗后3、6个月进行门诊随访,疼痛程度评估采用疼痛数值量表（numerical rating scale, NRS）评分;使用丹麦健康与医疗管理局（Danish Healthand Medicine Authority）满意度评分表评估治疗后病人满意度;肩关节功能评估采用美国加州大学洛杉矶分校（University of California at Los Angeles, UCLA）肩关节评分系统。结果 手术组术后切口恢复良好,均获得Ⅰ级愈合,未出现明显术后并发症。两组病人治疗后的NRS评分均显著低于治疗前,且手术组治疗后的NRS评分明显低于非手术组,差异有统计学意义（t=21.114,P=0.003）。根据丹麦健康与医疗管理局满意度评分表,手术组病人的满意度评分较非手术组高,差异有统计学意义（t=17.194,P=0.012）。手术组UCLA各项评分较术前均显著提高,差异均有统计学意义（P均＜0.001）;除疼痛项评分外,非手术组UCLA各项评分与术前相比,差异均无统计学意义（P均＞0.05）;手术组术后UCLA肩关节功能评分的优良率为100%（优23例、良8例,31/31）,非手术组为45%（优3例、良6例,9/20）,差异具有统计学意义（χ²=21.363,P＜0.001）。结论 行关节镜下肩袖修补治疗夹层型肩袖撕裂可以明显缓解病人的疼痛症状,增加肩关节活动度,改善肩关节功能,可获得更好的病人满意度。     

高脂血症病人股骨颈骨折分型的临床研究

目的 探究高脂血症病人股骨颈骨折的分型特点。方法 将2012年8月至2017年11月在湖北省宜昌市第二人民医院骨外科和云南省中医医院骨科诊断为股骨近端骨折并符合纳入标准的196例病人作为研究对象,分为高血脂组（97例）和血脂正常组（99例）。根据股骨颈骨折部位及股骨转子间Evans骨折分型判断各例病人的骨折类型。入院及出院时分别检测各例病人的总胆固醇及低密度脂蛋白胆固醇（low density lipoprotein cholesterol, LDL-C）水平,将高血脂组按照高血脂病程分为短期组（≤1年）、中期组（＞1年,≤3年）和长期组（＞3年）。探究血脂水平与股骨颈骨折分型之间的潜在规律。结果 高血脂组股骨颈骨折者81例（83.5%）,显著高于血脂正常组的67例（67.7%）,差异有统计学意义（χ²=6.638,P=0.010）;长期组以颈中型骨折（19例,61.3%）最为多见,与短期组（1例,6.7%）、中期组（12例,23.5%）相比,差异有统计学意义（χ²=12.973,P=0.004;χ²=16.413,P均＜0.001）。高血脂组中,中、长期组血脂水平（总胆固醇、LDL-C）均高于短期组,差异均有统计学意义（P均＜0.05）。结论 合并长期（＞3年）高脂血症的股骨颈骨折病人中,以股骨颈颈中型骨折较为多见。     

高低位腰椎椎间盘突出症患者脊柱-骨盆矢状面形态变化

目的 比较高位与低位腰椎椎间盘突出症（LDH）患者脊柱-骨盆矢状面形态学差异，探讨脊柱-骨盆矢状面形态学参数异常与高位LDH发生的关系。方法 纳入2006年1月—2022年1月收治的高位LDH患者53例（高位组），同时期性别、年龄和体质量指数（MBI）匹配的低位LDH患者53例（低位组）及单纯下腰部疼痛的非LDH患者53例（对照组）。在站立位全脊柱侧位X线片上测量3组矢状面平衡（SVA）、胸椎后凸角（TK）、腰椎前凸角（LL）、腰骶前凸角（LSL）、骶骨倾斜角（ST）、骨盆入射角（PI）、骨盆倾斜角（PT）、骶骨倾斜角（SS）等脊柱-骨盆矢状面参数。结果 高位组SVA、TK明显高于对照组，LL、ST、PI、PT及SS明显低于对照组；高位组TK明显高于低位组，LL、ST及PI明显低于低位组；差异均有统计学意义（P<0.05）。高位组L₁/L₂节段患者的LL、ST较L₂/L₃节段患者有下降趋势，但差异无统计学意义（P>0.05）。结论 骨盆水平化导致的胸腰段过度代偿可能是高位LDH发生、发展的机制之一。     

Factors associated with acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time lateral patellar dislocation: A prospective magnetic resonance imaging study

ObjectivesTo identify risk factors of acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time lateral patellar dislocation (LPD).MethodsMagnetic resonance images were prospectively analyzed in 115 patients in an acute first-time LPD. Factors included gender, skeletal maturity, trochlear dysplasia, patellar height, and tibial tuberosity–trochlear groove (TT-TG) distance. Binary logistic regression analysis was carried out to identify the independent risk factors for the incidence of acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time LPD.ResultsThe incidence of acute articular cartilage lesion of the patella and lateral femoral condyle were 46.1% and 27% in acute first-time LPD, respectively. Univariate analysis revealed significantly higher incidence rate of acute articular cartilage lesion of the patella in male (P = 0.027), skeletally mature (P = 0.035), normal TT-TG distance (P = 0.043) and normal femoral trochlea (P = 0.031). Risk factors for the incidence of acute articular cartilage lesion of the patella were skeletally mature (odds ratio (OR): 2.324), normal TT-TG distance (OR: 2.824) and normal femoral trochlea (OR: 3.835). Univariate analysis revealed significantly higher incidence rate of acute articular cartilage lesion of the lateral femoral condyle in skeletally mature (P = 0.027) and normal femoral trochlea (P = 0.031). Risk factor for the incidence of acute articular cartilage lesion of the lateral femoral condyle was normal femoral trochlea (OR: 3.347).ConclusionsFor patients in acute first-time LPD, compared with other parameters, the normal femoral trochlea, normal TT-TG distance and skeletally mature are independent risk factors for the incidence of acute articular cartilage lesion of the patella, and the normal femoral trochlea is an independent risk factor for the incidence of acute articular cartilage lesion of the lateral femoral condyle.     

The incidence of trochlear dysplasia in anterior cruciate ligament tears

Purpose

The purpose of the present epidemiologic study is to record the radiographic presence of trochlear dysplasia and patella alta in patients who undergo anterior cruciate ligament (ACL) reconstruction as a potential underlying factor for post-operative anterior knee pain (AKP).

Methods

All consecutive cases of skeletally-mature ACL-deficient knees that would undergo ACL reconstruction in three different hospitals were prospectively included during a six-month period. Inclusion criteria were acute and sub-acute ACL injury with no previous ipsilateral knee operation. Patients with chronic ACL tears, prior-to-ACL-injury history of patellar instability or other PF disorders were excluded from the study.

Results

A total of 299 knees were included (mean age 32 ± ten years). Forty-four (14.7 %) knees had a positive ‘crossing sign’ in the lateral X-rays and 255 (85.3 %) had no sign of trochlear dysplasia (p < 0.01). Among the cases with trochlear dysplasia, 41 (93 %) had type A trochlear dysplasia with the presence only of the ‘crossing sign’ and three (7 %) had type C trochlear dysplasia. Patellar height results included a mean Caton-Deschamps index of 1.0 ± 0.14 (0.5–1.4). Twenty (6.6 %) knees had an index of less than 0.8, and two (0.6 %) knees had an index less than 0.6. In contrast, 15 (5.0 %) knees had an abnormal value of more than 1.2, indicating patella alta.

Conclusions

The most important finding of the study is the increased prevalence of trochlear dysplasia and patella alta in patients with ACL injury, when compared to the incidence of trochlear dysplasia and patella alta in the general population in the literature. This finding could sound as an alert of a possible additional risk factor for post-operative anterior knee pain after ACL reconstruction.     

Chronische patellofemorale Instabilit?t

Chronic patellofemoral instability may lead to pain and early osteoarthrosis. Recurrent dislocations of the patella, lateral subluxation and chronic dislocation are summarized under this generic term. There are five different factors which may be responsible of the development of chronic patellofemoral instability: 1) elongation of the medial patellofemoral ligament (MPFL), 2) patella alta, 3) increased distance between tibial tuberosity and trochlea groove (TTTG) distance, 4) trochlea dysplasia and 5) torsional malalignment. To rule out these factors clinical examination, radiological diagnostics (luxation, subluxation in the Defilée view, trochlea morphology, patella alta) and magnetic resonance imaging (MRI) of TTTG distance and trochlea morphology are crucial. The indications of operative treatment are chronic pain with subluxation, chronic dislocation and recurrent dislocation. Currently the former frequently and universally used lateral release is only indicated in cases of subluxation and positive tilt. Biomechanical studies have shown that a lateral release will otherwise increase patellofemoral instability. The choice of the surgical technique depends on the factors underlying patellofemoral instability, the conditions of growth plate and cartilage damage. Among the different surgical options proximal and distal realignment procedures are differentiated. In cases of MPFL elongation and mild passive instability a medial reefing might be successful. In cases of MPFL elongation, high passive instability up to 30° of flexion (with or without trochlear dysplasia) MPFL reconstruction may be the treatment of choice. A trochleoplasty is rarely indicated. This treatment may be considered in cases of high grade trochlea dysplasia and passive instability at more than 30° of flexion. If the TTTG distance is increased (>20 mm) or in cases of patella alta distal realignment with tibial tubercle transfer should be considered. This operation might also be useful in the presence of lateral cartilage damage as an anteromedialization of the patella.     

Editorial Commentary: When Properly Indicated,Combined Tibial Tubercle Osteotomy Reduces Risk of Recurrent Patellofemoral Instability More Than Does Isolated Medial Patellofemoral Ligament Reconstruction

Clinical recognition and surgical treatment of patellofemoral instability has evolved dramatically over the past 3 decades. However, few patellofemoral patients present with an isolated medial patellofemoral ligament (MPFL) tear. Rather, patients often demonstrate patella alta, increased tibial tubercle to trochlear groove (TT-TG) distance, dysplasia, coronal malalignment, or combinations thereof. Given this, concomitant procedures such as tibial tubercle osteotomy (TTO) have become increasingly popularized, given their ability to anteriorize, medialize, and even distalize the patella to correct tracking. It is generally recommended that concurrent TTO be considered with primary medial patellofemoral ligament reconstruction (MPFLR) in patients with closed physes whose TT-TG distance is larger than 17 to 20 mm. MPFLR + TTO is generally safe and may decrease risk of revision surgery when compared with isolated MPFLR in properly indicated patients. However, it important to measure both knee rotation angle and tibial tubercle lateralization on magnetic resonance imaging, as both factors influence TT-TG. In patients in whom abnormal knee rotation angle is felt to be the primary driver of TT-TG, surgeons should proceed with caution when considering concomitant TTO. The pen may be mightier than the sword, but the osteotome may be mightier yet than the scalpel.     

The sulcus angle and malalignment of the extensor mechanism of the knee

Anterior knee pain due to dysplasia of the extensor mechanism is common. We have studied 137 knees (103 patients) in order to identify a rapid and reproducible radiological feature which would indicate the need for further analysis. Overall, 67 knees (49%) had at least one radiological abnormality; 70 (51%) were considered normal. There were five cases of Dejour type-3 dysplasia of the femoral trochlea, nine of type-2 and 12 of type-1. There were 49 cases of patella alta and five of patella infera. Four knees had an abnormal lateral patellofemoral angle (patellar tilt), and in 15 knees there was more than one abnormality. Classification of trochlear dysplasia was difficult and showed poor reproducibility. This was also true for the measurement of the lateral patellofemoral angle. Patellar height was more easily measured but took time. The sulcus angle is an easily and rapidly measurable feature which was reproducible and was closely related to other features of dysplasia of the extensor mechanism. The finding of a normal sulcus angle suggested that seeking other radiological evidence of malalignment of the extensor mechanism was unlikely to reveal additional useful information. The severity of other features of dysplasia of the extensor mechanism correlated with increasing sulcus angle.     

Gender-related differences in concomitant articular injuries after acute lateral patellar dislocation

ObjectivesTo explore the gender differences in the concomitant articular injuries after acute lateral patellar dislocation (LPD).MethodsMagnetic resonance images were prospectively analyzed in 166 patients after an acute LPD. Concomitant articular injuries included bone contusion, medial patellofemoral ligament (MPFL) injury, articular cartilage lesion, and vastus medialis obliquus (VMO) lesion. Statistical analyses were performed between the patient's gender and the incidence of concomitant articular injuries in adolescent and adult subgroups.ResultsThe incidence of partial and complete MPFL tear in adolescent males and females were (45%, 50%) and (63.2%, 29.8%), respectively. Compared with adolescent females, adolescent males showed higher incidence of complete MPFL tear (P = 0.049). The incidence of articular cartilage lesion of patella in adolescent males and females were 40% and 21.1%, respectively. Compared with adolescent females, adolescent males showed higher incidence of articular cartilage lesion of the patella (P = 0.043). No correlations were identified in other injuries in the adolescent group. The incidence of partial and complete MPFL tear in adult males and females were (34.4%, 65.6%) and (56.8%, 37.8%), respectively. Compared with adult females, adult males showed higher incidence of complete MPFL tear (P = 0.036). The incidence of articular cartilage lesion of patella in adult males and females were 56.3% and 32.4%, respectively. Compared with adult females, adult males showed higher incidence of articular cartilage lesion of patella (P = 0.047). The incidence of VMO injury in adult males and females were 59.4% and 35.1%, respectively. Compared with adult females, adult males showed higher incidence of VMO injury (P = 0.044). No correlations were identified in other injuries in the adult group.ConclusionsCompared with females, males predispose to complete MPFL tear and articular cartilage lesion of patella after acute LPD. Compared with female adults, male adults predispose to VMO injury.     

Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality

The aim of this study was to present the different surgical procedures of tibial tubercle osteotomies for patellar instability or patellar mispositioning such as patella alta or patella infera. This study analysed the Caton–Deschamps index used for assessment of vertical patella height in order to make a precise plan for tibial tuberosity osteotomies. This study included 61 knees (50 patients) treated for patellar instability with patella alta and 24 patients treated for patella infera of mechanical origin. The results of medial transfer of the tibial tuberosity, with or without distal transfer in cases of patellar instability with patella alta, gives excellent results for stability in 76.8% of the cases. The results of the proximal transfer of the tibial tuberosity in cases of patella infera were excellent or good in 80% of the cases in our series of 24 patients. A precise preoperative plan is needed with determination of the vertical patellar height using the Caton–Deschamps index and the situation of the tibial tuberosity and the Tibial Tubercle to Trochlear Groove distance (TT-TG) of the knee on CT scan in order to obtain satisfactory results.     

The relationship of anterior cruciate ligament injuries with MRI based calculation of femoral notch width,notch width index,notch shape - A randomized control study

BackgroundACL injuries are infamously known for disability in young adults and require surgical reconstruction. The need of time is to predict predisposing factors and prevent ACL injuries.The incidence of ACL injuries has been associated with various factors related to the morphology of distal femur and proximal tibia.Hence, purpose of this study was to assess the relationship of morphology of distal femur by assessing Notch Width(NW), Notch Width Index (NWI), and Notch shape calculated preoperatively on MRI in association with an ACL tear.MethodsThe following randomized control study had 60 patients enrolled with non contact injury to knee who were equally divided into 2 groups i.e. ACL injury group and control group. ACL group had patients who had MRI proven ACL tear along with clinical findings suggestive of ACL tear whereas control contained patients with intact ACL. Demographic data was collected and NW, NWI and Notch shape were determined on coronal sections of MRI sequences.ResultsPositive correlation of ACL tear was seen with NW, BCW, NWI, NWP, and NWJ. Smaller Notch Width showed higher incidence of ACL tear (p = 0.019). The mean NWI in the injured and control knee is 0.31 ± 0.01 and 0.27 ± 0.01 respectively and was statistically significant(p < 0.001). A shaped Notch (60%) was commonly seen in ACL tear group and U shaped notch (73.3%) was commonly seen in control group.We found the cut off value for the prediction of ACL tear of NWI was 0.29 with a sensitivity of 90% and specificity of 86.7%.ConclusionACL injuries in the given population have shown higher incidence with narrow femoral intercondylar notch, smaller notch width index, ‘A’ shaped femoral notch. If any of the above findings are present in the MRI, its important to counsel the subjects about the increased risk of ACL injuries in them and take preventive measures.     

Patellaluxation bei Sportlern

Most dislocations of the patella occur during sports activities. The entities instability, maltracking and loss of tracking should be defined by patient history, clinical examination and radiological evaluation including magnetic resonance imaging (MRI). Based on these criteria a new classification of patella dislocations (5 types) was established which allows a standardized treatment algorithm. Type 1 is a simple (traumatic) dislocation without maltracking and without instability. Type 2 has a high redislocation risk (defined as instability) without maltracking. An isolated stabilizing surgical procedure, such as medial patellofemoral ligament (MPFL) augmentation is successful in most cases. Type 3 is characterized by instability and maltracking. Maltracking can be caused by soft tissue contracture or muscular deficits (type 3a), patella alta (type 3b), pathological tibial tuberosity to trochlear groove (TT-TG) distance (type 3c), genu valgum (type 3d) and torsional deformities (type 3e). In these types an isolated soft tissue procedure is usually not sufficient. The bony pathologies additionally need to be addressed to regain physiological patella tracking. Type 4 includes severe trochlea dysplasia with loss of patella tracking. Usually trochleaplasty is needed to stabilize the patella and to prevent redislocation. Type 5 is based on patella maltracking without instability and can be found in patients with a pathological knee baseline or special forms of torsional deformities. Although patella dislocations in trained athletes are seldom due to the stabilizing muscular status, the treatment strategy is similar to that of normal persons. Additional cartilage injuries, type of sports and time for rehabilitation have to be considered for optimal treatment.