Increased external tibial torsion in Osgood-Schlatter disease

We studied the relationship between Osgood-Schlatter disease and torsional abnormalities of the lower limb in 21 boys with this condition and 20 age- and sex-matched controls. 3 groups of knees (20 control knees, 21 symptomatic and 21 asymptomatic or less symptomatic knees) were subjected to clinical, radiographic and CT evaluation. We found no statistically significant differences between patients and controls, as regards femoral anteversion, patellar congruence angle, patellar tilt angle and anterior tibial tuberosity-trochlear groove distance, but the condylomalleolar angle and tibial torsion angle were greater in patients. We found no differences between symptomatic and asymptomatic or less symptomatic knees in any of the parameters. All the symptomatic knees were on the side preferentially involved in jumping and sprinting. This increase in external tibial torsion may play a role as a predisposing mechanical factor in the onset of Osgood-Schlatter disease in male athletes.     

Increased external tibial torsion in Osgood-Schlatter disease

We studied the relationship between Osgood-Schlatter disease and torsional abnormalities of the lower limb in 21 boys with this condition and 20 age- and sex-matched controls. 3 groups of knees (20 control knees, 21 symptomatic and 21 asymptomatic or less symptomatic knees) were subjected to clinical, radiographic and CT evaluation. We found no statistically significant differences between patients and controls, as regards femoral anteversion, patellar congruence angle, patellar tilt angle and anterior tibial tuberosity-trochlear groove distance, but the condylomalleolar angle and tibial torsion angle were greater in patients. We found no differences between symptomatic and asymptomatic or less symptomatic knees in any of the parameters. All the symptomatic knees were on the side preferentially involved in jumping and sprinting. This increase in external tibial torsion may play a role as a predisposing mechanical factor in the onset of Osgood-Schlatter disease in male athletes.     

Natural history of Osgood-Schlatter disease

The natural history of untreated Osgood-Schlatter disease is presented in the retrospective study of 69 knees in 50 patients. Seventy-six percent of the patients believed they had no limitation of activity, although 60% still could not kneel without discomfort. Two groups of patients were identified: those who presented with radiologic fragmentation and had either separated ossicles or an abnormally ossified tuberosity at review, and those who presented with soft tissue swelling without radiologic fragmentation and were asymptomatic at review. There was a low incidence of patellar instability or anterior knee pain, and no case of premature proximal tibial epiphyseal arrest.     

Results of surgical treatment of unresolved Osgood-Schlatter disease in adults

Osgood-Schlatter is a common disease with most cases resolving spontaneously with skeletal maturity. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative measures. The purpose of this study is to describe the pathological lesions, our surgical technique, and the results of our surgical treatment of Osgood Schlatter disease in adults. Thirty-five adult patients (37 knees) had surgery for unresolved Osgood-Schlatter disease. Three patients were lost for follow-up. An incision over the anterolateral aspect of the patellar tendon was used. Direct anterior incisions were avoided to decrease postoperative pain with kneeling. The patellar tendon was reflected medially, and the ossicle was removed from the posterior surface of the tendon. A tibial tuberosity reduction osteotomy was done in 29 cases (85%). A beak of the distal part of the tibial tubercle was found in 24 cases (71%) with impingement of the patellar ligament. Thirty-one knees (91%) had complete resolution of preoperative pain. There was one case of painful scar. This surgical technique for treatment of Osgood-Schlatter disease in adults is effective and safe especially for those who have the habit of frequent kneeling.     

Patellar angle in Osgood-Schlatter disease

A new patellar angle is described in lateral radiographs of the knee joint. One line is drawn along the articular surface of the patella and another from the end of the inferior articular cartilage to the patellar apex. The angle formed by these two lines averaged 33 degrees in 68 knees joints afflicted with Osgood-Schlatter disease and 47 degrees in 71 age-matched controls and 198 adult controls. The small angle in Osgood-Schlatter disease is proposed to be an important factor in the pathogenesis of the traction apophysitis.     

Patellar angle in Osgood-Schlatter disease

A new patellar angle is described in lateral radiographs of the knee joint. One line is drawn along the articular surface of the patella and another from the end of the inferior articular cartilage to the patellar apex. The angle formed by these two lines averaged 33° in 68 knees joints afflicted with Osgood-Schlatter disease and 47° in 71 age-matched controls and 198 adult controls. The small angle in Osgood-Schlatter disease is proposed to be an important factor in the pathogenesis of the traction apophysitis.     

Ultrasonic features of the Osgood-Schlatter lesion

Ultrasound was used to compare the knees of 10 boys and four girls with typical clinical Osgood-Schlatter lesions with 27 symptomless knees. The normal sonographic changes of the tibial tubercle with advancing age are described. In all children with Osgood-Schlatter lesions, the distal patellar tendon thickened and became more echogenic than normal tendons, and an anechoic zone of edema was seen anterior to the tibial tuberosity. Four knees disclosed a thin shell-like elevated fragment of the tibial tuberosity seen as an echogenic surface. In 12 knees, single or multiple fragments of the tibial tuberosity were easily shown. Ultrasound is proposed as a simple, fast, and reliable method for the diagnosis of the Osgood-Schlatter lesion.     

A study on torsion of the lower leg in osteoarthritis of the knee. Measurement of leg torsion by computerized tomography

Lower leg torsion was measured by computerized tomography (CT-scan) in the knees with osteoarthritis. Materials and Methods: Experimental studies; Using the Toshiba CT/TCT-60A, the degree of torsion in five dried tibias were measured in three positions of varus, 0 degrees, 10 degrees and 20 degrees; and in two positions of flexion 0 degrees and 20 degrees. Clinical studies; The degree of tibial torsion was measured by CT-scan in 68 adult patients (85 knees) and compared with the torsion in 13 controls (24 tibias). The correlation between tibial torsion and osteoporosity was investigated by measuring CT-density of the third lumbar vertebra. Results: No statistically significant difference was found among the results of measurement obtained in five dried tibias placed in three positions of varus and in two positions of flexion. These results indicate that measurement of torsion using CT-scan is not influenced by the position when varus and flexion deformity are less than 20 degrees. Osteoarthritic knees were divided into five radiographic stages. There were significant differences between the lateral tibial torsions for each stage. The lateral tibial torsion was 23.5 degrees in normal adults, 14.1 degrees in stage II, 11.9 degrees in stage III, 7.5 degrees in stage IV and V, for an average of 11.3 degrees. The rate of decrease in lateral tibial torsion was 59.6% in the proximal tibia, 4.2% in the tibial shaft and 36.2% in the distal tibia. The decreases of lateral tibial torsion were correlated with decrease of CT-density of the third lumbar vertebra. Conclusion: It is apparent from this study that there is a correlation between decreasing lateral tibial torsion with the radiographic stage of osteoarthritis of the knee and general osteoporosity.     

A modified system of stress radiography for patellofemoral instability

Axial radiographs were obtained under valgus and external rotation stress at 45 degrees of knee flexion with and without contraction of the quadriceps muscle in order to assess the dynamics of patellar subluxation or dislocation. The radiography was performed on 82 knees in 61 patients with patellofemoral instability, and on 44 normal knees. The lateral patellofemoral angle and the congruence angle were measured and compared with the conventional Merchant views. Both parameters showed greater differences between symptomatic and normal knees on the stress radiographs obtained without quadriceps contraction. There was a major difference in the lateral patellofemoral angles between the groups, which clearly distinguished symptomatic knees from normal controls. Congruence angles on stress radiography had a significant correlation with the functional scores obtained after a period of conservative treatment and a positive correlation with the frequency of patellar subluxation. When the quadriceps contracted, two patterns of patellar shift were observed. While the patella reduced into the trochlear groove in all normal knees and about 70% of the symptomatic knees, contraction of the quadriceps caused further subluxation of the patella in the remaining symptomatic knees. All the knee joints which showed this displacement failed to respond to conservative treatment and eventually required surgical treatment. Thus, this technique of stress radiography is a simple, cost-effective and useful method of evaluating patellar instability and predicting the prognosis.     

Open-wedge osteotomy of the proximal tibia hemicallotasis.

Conventional high tibial osteotomy for losteoarthritis of the medial compartment of the knee with closed-wedge or dome osteotomy (DMO) may produce shortening of the patellar tendon and loss of inclination of the proximal tibial plateau or of the offset of the tibial condyle relative to its bony axis. This can make subsequent total knee arthroplasty technically demanding. We undertook a prospective study comparing these changes after DMO with those after using open-wedge osteotomy hemicallotasis (HCO). A total of 50 knees with arthritis of the medial compartment in 46 consecutive patients was randomly allocated to either DMO or HCO. There were no significant differences between the groups with regard to age, gender, femorotibial angle before operation or the angle of correction. Radiological studies showed that HCO caused little change in the length of the patellar tendon or the inclination angle of the tibial plateau, while after DMO both gradually decreased. The degree of tibial condylar offset increased in both groups, but less so in the HCO group.     

Posteriorly stabilised total-condylar knee replacement. Three to eight years' follow-up of 85 knees

We have reviewed 85 knees in 71 patients after total-condylar posteriorly stabilised (Insall-Burstein) knee replacement with an average follow-up of five years. Excellent or good results were obtained in 90% with an average maximum flexion of 98 degrees. The four poor results (5%) included two with deep infection, one with patellar dislocation and one with loosening. Four other knees (5%) showed signs of probable tibial loosening, but the patients were asymptomatic, the clinical results had not deteriorated with time and lucent lines had not progressed. Varus alignment of the knee and a varus tilt of more than 2 degrees of the tibial component correlated with the incidence of lucent lines around the tibial implant. No patellar stress fractures were seen but impingement symptoms were present in 20%, although they were troublesome in less than half of them. The virtue of the prosthesis lies in its versatility for use in the severely deformed joint.     

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation

Osgood-Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.     

Axial computed tomography of the patellofemoral joint with and without quadriceps contraction

Computed tomography was used to analyze the patellofemoral relationship during the first 60° of knee flexion in patients with chronic patellofemoral pain syndrome (49 knees) and a healthy control group (15 knees). The patellofemoral joints were imaged axially through the center of the patella articular cartilage with the knee flexed 0°, 0° with maximal quadriceps muscle contraction, 30°, and 60°. In 0° of knee flexion, the sulcus angle was greater in the symptomatic group than in normal controls. The patella displaced further laterally, and the lateral patellar tilt was greater. The patellar lateral index was found to be greater at 0° and indicated severe abnormality with full quadriceps muscle contraction. The Laurin angle was pathologic with increased medial opening, especially with muscle contraction. At 30° of knee flexion, these differences were less marked than at 0°. No relevant differences were found with 60° of knee flexion. This study showed that the sulcus angle, lateral patellar displacement, lateral patellar tilt, patella lateral condyle index, and Laurin angle are relevant diagnostic features in 0° of knee flexion, indicating a pathological femoral patellar gliding mechanism. Our evaluation also demonstrated the influence of full quadriceps muscle contraction, especially regarding lateral patellar displacement and the Laurin angle, and it was most prominent on the patella lateral condyle index. Thus, quadriceps muscle contraction often creates a more pathological displacement of the patella, which can be depicted using axial computed tomography.     

Radionuclide imaging of asymptomatic versus symptomatic total knee arthroplasties

Ninety-eight total knee prostheses were evaluated by roentgenograms and bone scans. Fifty-three were asymptomatic, and 45 were symptomatic. Thirteen prostheses required revision surgery. At a mean of 54 months, asymptomatic knee replacements generally showed only mild uptake in one or more zones. Only one knee had uptake equal to surrounding bone. However, symptomatic knee replacements showed significantly greater uptake in the patella, femur, and medial and lateral tibial plateau regions (Mann-Whitney two-sample rank test). Bone scans in the symptomatic group were obtained at a mean of 44 months. Excluding those patients who had revision surgery, the differences remained significant. Furthermore, symptomatic knee replacements with normal roentgenograms also had significantly greater uptake. Radiolucent lines were noted in 30% of asymptomatic patients, whereas 29% of symptomatic knees had radiolucencies. Radiolucencies were not generally associated with significantly greater uptake. Lateral release had no effect on the patellar score.     

Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty

The mainstay of treatment of Osgood-Schlatter apophysitis is nonoperative. Surgical treatment has been described for patients who have failed nonoperative management of Osgood-Schlatter disease. The purpose of this study is to evaluate the functional outcome of ossicle excision and tibial tubercleplasty for unresolved Osgood-Schlatter disease that has failed nonoperative treatment. METHODS: A retrospective review was performed on 16 knees in 15 patients who underwent ossicle excision and tibial tubercleplasty for unresolved Osgood-Schlatter disease. Functional outcome was assessed using the International Knee Documentation Committee, the Lysholm Knee Scale, and Tegner Activity Score. RESULTS: Twelve patients (75%) returned to preoperative activities and sports, 2 patients (12.5%) partially returned, and 1 patient (6%) did not return. The mean postoperative Lysholm knee score was 76.5. Patients' individual scores ranged from 40 to 100. The mean International Knee Documentation Committee knee score was 75, ranging from 40 to 100. The mean Tegner activity level was 6.8 (range, 3-10). CONCLUSIONS: It is our recommendation that when patients fail extensive nonoperative management, surgery to remove the symptomatic ossicle should be offered after skeletal maturity. When this is the case, the addition of tubercleplasty should be performed.     

髌骨半脱位70例治疗分析

目的探讨髌骨半脱位的治疗方法及其预后。方法回顾性分析70例（130膝）髌骨半脱位患者的临床资料,其中男30例,女40例;年龄10～48岁,平均23岁。患者髌骨的形态均为WibergⅡ、Ⅲ型,其中伴有外侧髌股关节骨关节炎者58例108膝,高位髌骨23例46膝,外伤后股四头肌内侧头肌张力不良10例10膝。Q角20°～40°。全部行手术治疗,手术方式包括：髌外侧支持带充分松解（130膝）;髌内侧支持带紧缩、股内侧肌移位至髌骨前内侧（12膝）;髌骨外侧部分切除（17膝）;胫骨结节前、内侧移位（46膝）,平均内移1．0cm、前移1．2cm;缝匠肌前移（11膝）,半腱肌前移（13膝）;关节镜下髌外侧支持带松解,髌内侧支持带紧缩（31膝）。术中见全部病例髌外侧支持带均明显增厚。结果随访3～180个月,根据Insall等评分系统评估分析疗效,术后疗效优78膝,良33膝,可12膝,差7膝。患者术后疼痛、关节活动功能均得到明显改善,尤其是解除膝前痛效果显著。结论根据病因及病理改变选择恰当的手术方式治疗髌骨半脱位均可取得满意的效果,特别是关节镜手术具有创伤小、恢复快的特点,值得进一步推广应用。     

Tibial torsion in patients with medial-type osteoarthritic knee

Computed tomography measurements of tibial torsion were evaluated in 85 patients with medial-type osteoarthritic knees and in 24 normal adults. Although there were no differences in the degrees of femoral torsion or knee joint rotation, external tibial torsion was observed to have a mean value of 11.3 degrees, significantly smaller than the 23.5 degrees observed in the normal adults (p less than 0.01). The more advanced the osteoarthritic stage, the greater was the reduction in external tibial torsion. Reduction of external torsion of the tibia was most severe at the proximal tibial metaphysis.     

In vivo movement analysis of the patella using a three-dimensional computer model

We used three-dimensional movement analysis by computer modelling of knee flexion from 0 degrees to 50 degrees in 14 knees in 12 patients with recurrent patellar dislocation and in 15 knees in ten normal control subjects to compare the in vivo three-dimensional movement of the patella. Flexion, tilt and spin of the patella were described in terms of rotation angles from 0 degrees . The location of the patella and the tibial tubercle were evaluated using parameters expressed as percentage patellar shift and percentage tubercle shift. Patellar inclination to the femur was also measured and patellofemoral contact was qualitatively and quantitatively analysed. The patients had greater values of spin from 20 degrees to 50 degrees , while there were no statistically significant differences in flexion and tilt. The patients also had greater percentage patellar shift from 0 degrees to 50 degrees , percentage tubercle shift at 0 degrees and 10 degrees and patellar inclination from 0 degrees to 50 degrees with a smaller oval-shaped contact area from 20 degrees to 50 degrees moving downwards on the lateral facet. Patellar movement analysis using a three-dimensional computer model is useful to clearly demonstrate differences between patients with recurrent dislocation of the patella and normal control subjects.     

Ten- to 12-year followup of the Insall-Burstein I total knee prosthesis

The Insall-Burstein Posterior Stabilized knee prosthesis (Insall-Burstein I), developed at The Hospital for Special Surgery in 1978, has a metal-backed nonmodular tibial component. The polyethylene articular surface was directly molded. The purpose of the current study was to evaluate long-term wear with this design. The first 100 total knee arthroplasties (86 patients) performed by the senior author were followed prospectively. The average age of the patients at the time of surgery was 69.7 years (range, 45-89 years). The primary diagnoses were osteoarthritis in 77 knees (66 patients), inflammatory arthritis in 17 knees (14 patients), and posttraumatic arthritis in the remaining six knees (six patients). Thirty-eight knees (35 patients) had varus angulation, 14 knees (13 patients) had valgus angulation, and 48 knees (40 patients) had a 0 degrees to 10 degrees tibiofemoral angle preoperatively. All patients were evaluated at 10 to 12 years followup. Knee Society scores and radiographs were obtained. Thirty-six knees were in 30 patients who had died and two knees were in two patients who were infirm. Telephone evaluation only was available for eight knees (seven patients), leaving 54 knees (47 patients) for direct clinical and radiographic evaluation. No patients were lost to followup. The average Knee Society clinical score at latest followup was 91.6 points. The average function score was 69 points. One knee arthroplasty failed because of tibial loosening, one failed because of patella wear and fracture, two failed because of sepsis, and two failed because of nonspecific pain. There were seven patella fractures (7%) in the 100 knees. One of the fractures resulted in a total knee revision (noted above), two resulted in patellar component revision, and another resulted in patellar component removal. The remaining three patella fractures were discovered incidentally and were asymptomatic. There were no patellar dislocations. At long-term radiographic analysis, valgus alignment averaged 6 degrees (range, 0 degrees-11 degrees). Polyethylene wear averaged 0.40 mm. There was no catastrophic wear of tibial polyethylene. Thirty-two knees in 32 patients (65%) had radiolucencies in at least one zone; no lucency filled a zone, and none was wider than 2 mm. The absence of clinically significant tibial polyethylene wear at long-term followup is of particular interest. The performance of the molded, nonmodular polyethylene articulation is encouraging and needs to be analyzed critically against the more widely used machined, modular components used today.     

Tibial sequestrectomy in the management of Osgood-Schlatter disease

Two groups of patients with symptomatic Osgood-Schlatter disease were compared over a 4-5 year follow-up period. One group was treated surgically by tibial sequestrectomy and the other group was managed conservatively. Tibial sequestrectomy was found to offer no significant benefit over simple conservative methods of treatment. In addition, a significant complication rate was identified with this procedure.