Quadriceps Tendon Autograft Medial Patellofemoral Ligament Reconstruction

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.

Summary

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.

     

Avoiding Complications with MPFL Reconstruction

Purpose of Review

To discuss the potentially significant complications associated with medial patellofemoral ligament (MPFL) reconstruction. Additionally, to review the most current and relevant literature with an emphasis on avoiding these potential complications.

Recent Findings

Multiple cadaveric studies have characterized the anatomy of the MPFL and the related morphologic abnormalities that contribute to recurrent lateral patellar instability. Such abnormalities include patella alta, excessive tibial tubercle to trochlear grove (TT-TG) distance, trochlear dysplasia, and malalignment. Recent studies have evaluated the clinical outcomes associated with the treatment of concomitant pathology in combination with MPFL reconstruction, which is critical in avoiding recurrent instability and complications.

Summary

Although there remains a lack of consensus regarding various critical aspects of MPFL reconstruction, certain concepts remain imperative. Our preferred methods and rationales for surgical techniques are described. These include appropriate work up, a combination of procedures to address abnormal morphology, anatomical femoral insertion, safe and secure patellar fixation, appropriate graft length fixation, and thoughtful knee flexion during fixation.

     

Arthroskopische Therapie der Kniesteife

Background

Knees with a limited range of motion caused by intraarticular scars benefit from arthroscopic arthrolysis. Usually these scars result from previous surgery, severe trauma with damage of intraarticular structures.

Objectives

The aim of this procedure is to improve the patients’ range of motion which is necessary for activities of work and daily life. Scar tissue is debrided and resected arthroscopically with a radiofrequency device, a shaver or a punch.

Indications

Indications are a flexion deficit of max. 40°, an extension deficit of max. 20°, reduced mobility of patella, intraarticular reason for limited range of motion, cyclops after anterior cruciate liagment reconstruction, fibrotic Hoffa fat pad.

Contraindications

Contraindications are an extraarticular origin of limited range of motion (e.?g. fibrotic quadriceps muscle), local and general infection, major osteoarthritis, noncompliance, complex regional pain syndrome type I.

Postoperative management

A continuous physical therapy to maintain range of motion is essential. If necessary, continuous passive motion is implemented. Pain adapted weight-bearing should be used for mobilization. A sufficient oral and (when indicated) regional pain management is important to guarantee the benefit of the surgery.

Results

Patients with a lack of mobility of the knee gain a significantly increased range of motion by this arthroscopic procedure. Because of the minimal invasiveness, trauma of surgery and risk of infection are reduced. In many cases the function of the knee joint can be completely restored or at least improved considerably. Complications such as early osteoarthritis can be avoided.

     

Quietschendes Kniegelenk nach VKB-Rekonstruktion und Refixation der Außenmeniskushinterhornwurzel

Introduction

A posterior root tear of the lateral meniscus is a common concomitant injury of anterior cruciate ligament (ACL) ruptures. Transtibial pull-out repair is an established surgical treatment for isolated posterior root tears. Due to the anatomical relationship, the tibial tunnel of the ACL can be used to fix the meniscus suture in a simultaneous ACL reconstruction.

Case report

We report on a 43-year-old male patient who was treated with ACL reconstruction and simultaneous transtibial pullout repair of the posterior root of the lateral meniscus of the right knee joint. After 3 months the patient complained about a creaking knee joint. Revision arthroscopy showed a failure of the transtibial pull-out suture. The fiber thread of the suture was displaced into the knee joint and was responsible for the creaking sensation.

Conclusion

The simultaneous use of the tibial ACL tunnel to fix the posterior root of the lateral meniscus is an efficient option. In the case of technical difficulties of tibial ACL fixation using interference screws, a separate tunnel for posterior root fixation provides a secure alternative to avoid accidental tearing of the thread of the pull-out suture.

     

Aspekte einer liaisonpsychiatrischen Betreuung von Patienten einer universitären Schmerzambulanz

Background

Owing to a rise of psychosomatic comorbidities, the treatment of psychological disorders, which may negatively impact prognosis and therapy, is increasingly becoming a focus of attention for pain outpatient clinics.

Aim

This study investigates and discusses the advantages of liaison psychiatric care in a university pain clinic.

Methods

In this retrospective study, we investigated all patients who presented to an anaesthesiologically led pain clinic between January and June 2014. The psychiatric history was taken by the liaison psychiatrist of the pain clinic.

Results

In the period investigated, 485 patients were treated as outpatients. A psychiatric diagnosis was present 351 patients (72.4%). The distribution of the diagnoses was comparable with that of a consultation service. Adaptation and affective disorders dominated. The patients were preferentially treated with new generation antidepressants.

Conclusion

The constant presence of a liaison psychiatrist allows for timely, specialised care of pain patients in terms of a multimodal therapeutic approach.

     

Labrumrekonstruktion – wie ist die Evidenz?

Background

The labrum is a biomechanically important structure of the hip joint. In the event of labral loss the new technique of labral reconstruction is aimed at restoring the anatomy and function of the labrum and thus prevention of joint degeneration.

Objective

The results and evidence relating to labral reconstruction are presented.

Material and methods

The currently available studies were evaluated and the biomechanical and clinical articles on labral reconstruction are discussed.

Results

There are a large number of different indications and surgical variants of this procedure. Biomechanical and clinical studies concerning labral defects show that the situation is improved by a reconstruction.

Discussion

As a result of the small number of cases and the low quality of the publications, there is as yet a lack of clinical evidence concerning this new surgical method. The biomechanical results suggest that reconstruction of a segmental labral defect is plausible for selected cases. Initial clinical results have to be confirmed by further studies in the long term.

     

Achtsame Schmerztherapie

Background

The in part promising, in part discrepant efficacy of psychological treatment of chronic musculoskeletal pain indicates a demand for interdisciplinary assessment and corresponding treatment structures with differentiated degrees of psychological and syndrome-specific specialization within a multimodal orthopedic context. Acceptance of pain and psychological flexibility are strongly related to physical impairments caused by pain.

Objective

Goals are improved outcomes of medical and physical treatment measures as well as their flexible implementation in daily life through a differentially indicated psychological pain therapy focusing on pain acceptance and mindfulness.

Methods

This study employed the “active not doing and generating inner silence” exercise from mindful-based pain therapy (“Achtsamkeitsbasierte Schmerztherapie”, ABST).

Results

Pure observation of a problem without an attempt to solve it is unusual and strange. Prerequisites for such exercises are willingness to engage as well as courage and openness.

Conclusion

A differentiated indication for clinical psychological treatment or psychotherapy of pain—a highly specialized form of psychological pain therapy—should be based on the diagnostic criterium of pain acceptance.

     

Automatic adjustment of pressure support by a computer-driven knowledge-based system during noninvasive ventilation: a feasibility study

Objective

To evaluate the feasibility of using a knowledge-based system designed to automatically titrate pressure support (PS) to maintain the patient in a “respiratory comfort zone” during noninvasive ventilation (NIV) in patients with acute respiratory failure.

Design and setting

Prospective crossover interventional study in an intensive care unit of a university hospital.

Patients

Twenty patients.

Interventions

After initial NIV setting and startup in conventional PS by the chest physiotherapist NIV was continued for 45?min with the automated PS activated.

Measurements and results

During automated PS minute-volume was maintained constant while respiratory rate decreased significantly from its pre-NIV value (20?±?3 vs. 25?±?3?bpm). There was a trend towards a progressive lowering of dyspnea. In hypercapnic patients PaCO₂ decreased significantly from 61?±?9 to 51?±?2?mmHg, and pH increased significantly from 7.31?±?0.05 to 7.35?±?0.03. Automated PS was well tolerated. Two system malfunctions occurred prompting physiotherapist intervention.

Conclusions

The results of this feasibility study suggest that the system can be used during NIV in patients with acute respiratory failure. Further studies should now determine whether it can improve patient-ventilator interaction and reduce caregiver workload.

     

Armut und Schmerz

Background

Poverty is an important problem in Germany. The health effects of poverty can lead to a higher risk of disease and the arising of chronic affections. On the other hand chronic illness may support the development and continuance of poverty. The context of chronic pain and poverty has not been analyzed so far.

Objectives

We investigated the correlation between chronic pain and poverty.

Materials and methods

In a prospective manner we interviewed 20 patients with pain syndromes during our consultation hour regarding their household income. Further, data from the German Federal Statistical Office were analyzed with respect to the correlation between the incidence of a chronic pain diagnosis and household income.

Results

At 1546?€, the average household income of the patients studied was below the poverty level. The analyzed data showed that women suffered from chronic pain more often than men did and also had a lower income. Another economic inequality was found between Eastern and Western Germany. There was a statistically significant correlation between income and the incidence of the diagnostic codes for chronic pain (R52.1, 2, 9) for men.

Conclusion

Our investigation showed the correlation between chronic pain and poverty. A commitment and cooperation of German medical associations and federal politics is necessary to overcome this sociopolitical issue.

     

Mimische Aktivität differenzierter Schmerzintensitäten

Background

The monitoring of facial expressions to assess pain intensity provides a way to determine the need for pain medication in patients who are not able to do so verbally.

Objectives

In this study two methods for facial expression analysis – Facial Action Coding System (FACS) and electromyography (EMG) of the zygomaticus muscle and corrugator supercilii – were compared to verify the possibility of using EMG for pain monitoring.

Material and methods

Eighty-seven subjects received painful heat stimuli via a thermode on the right forearm in two identical experimental sequences – with and without EMG recording.

Results

With FACS, pain threshold and pain tolerance could be distinguished reliably. Multiple regression analyses indicated that some facial expressions had a predictive value. Correlations between FACS and pain intensity and EMG and pain intensity were high, indicating a closer relationship for EMG and increasing pain intensity. For EMG and FACS, a low correlation was observed, whereas EMG correlates much better with pain intensity.

Conclusions

Results show that the facial expression analysis based on FACS represents a credible method to detect pain. Because of the expenditure of time and personal costs, FACS cannot be used properly until automatic systems work accurately. The use of EMG seems to be helpful in the meantime to enable continuous pain monitoring for patients with acute post-operative pain.

     

The medial patellofemoral complex

Purpose of review

The purpose of this review is to describe the current understanding of the medial patellofemoral complex, including recent anatomic advances, evaluation of indications for reconstruction with concomitant pathology, and surgical reconstruction techniques.

Recent findings

Recent advances in our understanding of MPFC anatomy have found that there are fibers that insert onto the deep quadriceps tendon as well as the patella, thus earning the name “medial patellofemoral complex” to allow for the variability in its anatomy. In MPFC reconstruction, anatomic origin and insertion points and appropriate graft length are critical to prevent overconstraint of the patellofemoral joint.

Summary

The MPFC is a crucial soft tissue checkrein to lateral patellar translation, and its repair or reconstruction results in good restoration of patellofemoral stability. As our understanding of MPFC anatomy evolves, further studies are needed to apply its relevance in kinematics and surgical applications to its role in maintaining patellar stability.

     

Münzkopfschmerz

Background

Subcutaneous peripheral nerve field stimulation (sPNFS) is an established procedure for the treatment of chronic localized neuropathic pain of peripheral origin. The treatment of nummular headache primarily focuses on conservative methods with limited prospects of success. The role of sPNFS in the treatment of nummular headache has not been investigated as yet.

Question

Is the sPNFS an option in the management of nummular headache?

Materials and methods

In addition to a summary of established methods in the treatment of nummular headache, sPNFS as a possible form of therapy is discussed.

Results

A positive effect of sPNFS in terms of the treatment of nummular headache is shown.

Discussion

sPNFS stimulates free subcutaneous nerves and transmits a pleasant form of paraesthesia in the area of pain. If regular conservative therapy has already been exhausted, then sPNFS might be an effective new option in the treatment of nummular headache. sPNFS is a minimally invasive and low-risk procedure. However, the high treatment cost and restrictions regarding fitness to undergo MRI are points of criticism. Further studies are needed to define its potential and role in the treatment of nummular headache.

     

Use of TT-PCL versus TT-TG

Purpose of Review

The tibial tubercle-to-trochlear groove (TT-TG) distance and tibial tubercle-to-posterior cruciate ligament (TT-PCL) distance have both been proposed for use in the evaluation of patients with patellofemoral instability.

Recent Findings

While the TT-TG value may be confounded by several factors, including age, gender, body mass index, and varying degrees of knee flexion on cross-sectional imaging, recent literature supports its utility for differentiation of patients with and without patellofemoral instability, and stratification of patients with and without coronal malalignment. The TT-PCL describes pure lateralization of the tibial tubercle, and may be used in conjunction with the TT-TG to better understand the path taken by the extensor mechanism of the knee joint.

Summary

The TT-TG measurement is superior to the TT-PCL measurement for differentiating patients with patellofemoral instability from their stable counterparts, though TT-PCL may be useful in conjunction with TT-TG for better understanding the path of the extensor mechanism across the knee joint.

     

Offene Arthrolyse des Kniegelenks

Background

Loss of range of motion of the knee joint causes significant disability. Surgical treatment should include arthroscopic as well as open arthrolysis procedures.

Objectives

Impairments of extension and flexion can have capsular or extra-articular origins in the musculature. The techniques of open capsulotomy and interventions on the proximal and distal extension apparatus are presented.

Methods

Discussion on the indications and surgical techniques for open arthrolysis of the knee joint are presented based on own results and the available literature.

Results

The established surgical techniques can significantly improve the range of motion considering the severity of this case group.

Conclusions

An exact analysis of the cause of knee stiffness is necessary. Only intra-articular problems can be arthroscopically treated and open techniques are indicated when the stiffness is caused by an extra-articular pathology. The techniques are established and reproducible.

     

Elterliche Reaktionen auf kindlichen Schmerz

Background

Parental reactions to their child’s pain can comprise cognitive-affective and behavioral responses. Dysfunctional responses like parental catastrophizing may lead to an aggravation of the child’s pain.

Objectives

Aims of the online-based study were (1) to psychometrically evaluate existing questionnaires into cognitive-affective (Pain Catastrophizing Scale for Parents; PCS-P) and behavioral responses (Inventar zum schmerzbezogenen Elternverhalten; ISEV-E) within a sample of 105 healthy parents, and (2) to compare their responses to existing (inter)national clinical samples and to the reactions of 80 parents with self-reported chronic pain from the general population.

Methods

The assessment of parental pain-related reactions was online-based.

Results

While the factor structure of the ISEV-E could not be replicated, the three factors of the PCS-P could be replicated. Parental catastrophizing of the healthy parents was lower compared to clinical samples. Healthy parents did not differ from parents with chronic pain from the general population.

Conclusion

The results offer a basis to grade parental catastrophizing, so that risk-groups can be identified.

     

painApp – mobiles Schmerzmonitoring in der häuslichen Versorgung

Background

The use of a scientifically developed App for pain management in the home care setting is not yet established in Germany. The documentation of pain-specific data by the patients and the transfer into a web portal to be examined by the attending physician can help close the existing communication gap in pain management between consultations.

Objectives

The aim of the study was to develop a mobile health (mHealth) solution for optimizing pain management in the home care setting. The research questions focus on design and technical issues concerning layout and navigation of the painApp as well as user-relevant questions concerning pain management, such as pain at rest and pain during movement, taking pain medication and patient satisfaction with their pain situation.

Materials and methods

Within a 12-month period, the user-centered development and practice-based testing of the application painApp involved patients aged?≥?65 years. Within a formative evaluation, a total of four data collections and a final survey took place. During the same period, a web portal was developed and tested the documentation of the patient pain-specific data from the painApp with the participation of general practitioners.

Results and conclusions

The development of the painApp as a prototype was realized in the study with high acceptability by the patients. The painApp is able to establish digital communication with the general practitioner without any technical problems and allows the physician access to patient data in real time.