Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure

Background This paper describes a modification of the Elmslie-Trillat procedure that is usually performed in severe cases of habitual or recurrent patellar instability. Methods Eighteen knees (7 men and 8 women) treated for recurrent or habitual patellar dislocation were evaluated clinically and radiographically at a mean follow-up of 5 years (range 24 months to 9 years). The mean age at follow-up was 26.3 years (range 17–44 years). The IKDC and Kujala and Tegner scores were used for the clinical evaluation. Anteroposterior, lateral and Merchant views were done for radiographic monitoring. When the patella was still unstable during dynamic evaluation after execution of the Elmslie-Trillat procedure, the medial third of the patellar tendon was isolated and harvested with a corresponding 1 cm long and 0.5 cm wide bone plug, maintaining its insertion to the inferior medial side of the patella. This ligament was medialized and put under tension, trying to find a medial insertion that guaranteed patellar stability throughout the full range of motion. Results IKDC classified 11 knees as A (normal), 4 knees as B (almost normal), 2 knees as C (abnormal) and 1 knee as D (severely abnormal). The Kujala score showed excellent results in 16 knees, 1 fair and 1 poor knee. The mean Tegner score rose from 2 preoperatively to 5 at follow-up. The poor knee presented an over-correction of the congruence angle on radiography. On follow-up radiographs, the parameters were almost completely corrected. Statistical analysis showed a significant correction of radiograph parameters, and significantly worse results in patients who underwent trochleoplasty. Conclusion The technique described tries to achieve a dynamic stability of the patella throughout the full range of motion in severe patellar instability where the Elmslie-Trillat procedure is insufficient. No recurrence of patellar instability has been observed. The stability must be obtained with dynamic control in the initial degrees of flexion, trying to avoid an excessive patellar medialization.     

Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella

We examined 39 patients (45 knees) who had undergone an Elmslie-Trillat procedure for recurrent or habitual dislocation of the patella with a follow-up of more than ten years. The mean age at the time of surgery was 18.4 years; the mean follow-up was 161 months (120 to 238). Using Fulkerson's functional knee score, 41 knees (91%) had an excellent or good result at a mean follow-up of 45 months, and this was maintained in 29 (64%) at the final review. The main cause of deterioration in the clinical results was the onset or worsening of patellofemoral joint pain, not patellar instability.     

High tibial osteotomy for the treatment of osteoarthritis of the knee: a review of the literature and a meta-analysis of follow-up studies

Introduction Proximal tibial osteotomy produces satisfactory early results, but these good results deteriorate with time. A meta-analysis, a set of statistical procedures designed to accumulate experimental and correlational results across independent studies, was undertaken to determine the final outcome of high tibial osteotomy of the knee.Materials and methods Following a comprehensive literature search from 1970 through 1998, the data of 19 relevant published studies were analysed in three separate arms.Results High tibial osteotomy had an averaged probability of a good or excellent result in 75.3% of the patients after 60 months and 60.3% after 100 months. The overall failure rate, including re-osteotomies, arthroplasties, meniscectomies, ligament reconstructions, infections and non-unions, was 24.6% at 10 years. The probability for total knee arthroplasty was 0.034 before 24 months, 0.078 between 24 and 47 months, and 0.114 between 48 and 71 months.Conclusions The meta-analysis showed that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months. Unchanged and mild pain was considered an unsatisfactory result. Knowing the natural cause of the disease, it is likely that most of these patients also gained from their operation to some extent, although the outcome was not as good as expected. However, we believe that there is a role for closed tibial osteotomy, as an alternative to total knee arthroplasty, only in carefully selected young patients.     

Tibial condylar valgus osteotomy (TCVO): Surgical technique and clinical results for knee osteoarthritis with varus deformity

Tibial condylar valgus osteotomy (TCVO) is an intra-articular proximal tibial osteotomy developed in 1989 and has since been used for the treatment of knee osteoarthritis (OA) associated with genu varum. This article describes the surgical technique and clinical results of TCVO. TCVO can be used for all grades of varus knee OA in patients of any age. he preoperative range of movement should be at least 90°. Preoperative screening showed varus-valgus instability due to an intra-articular deformity of the proximal tibia. Using intraoperative image intensification, a sagittally oriented “L”-shaped osteotomy is made from the medial to the tibial tuberosity to the center of the tibial plateau between the medial and lateral tibial spines. The separation of the osteotomy using the lamina spreader is gradually increased using an image intensifier guidance until the articular surface of the lateral tibial plateau comes in contact with the articular surface of the lateral femoral condyle. Adequate correction is indicated by parallelism of the lateral tibial plateau and a line tangential to the distal convexity of the lateral femoral condyle on an anteroposterior (AP) image and the elimination of the valgus instability with the knee in extended position. A “T”-plate (locking or non-locking plate or circular external fixator) is used to fix the osteotomy in the corrected position. Synthetic or autologous bone grafts can be used. We used the Japanese Orthopaedic Association score to evaluate the patient's function and also measured the %MAD, medial plateau opening angle, medial plateau angle, and lateral plateau opening angle on an AP view of the long length roentgenogram of the lower limb (standing position). The JOA score, radiologically measured values, and instability of the knee joint remarkably improved.     

Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature

Sonographic examination of the knee has been proposed by several authors in the past as a simple and reliable method to diagnose Osgood-Schlatter disease (OSD). Ultrasound was used to compare the knees of 25 boys and 10 girls with typical OSD with 35 symptom-free knees of an aged-matched group of children. Based on recorded data, patients were categorized (one affected knee in each individual) according to the classification system proposed by De Flaviis et al. in 1989. The results included the following pathological findings: pretibial swelling, fragmentation of the ossification center, insertional thickening of the patellar tendon, and excessive fluid collection in the infrapatellar bursa. Of our patients, 26% fell into the type 1 category, 43% were type 2, 20% type 3, and 11% type 4. This distribution of cases was found to be statistically similar to the initial findings reported by De Flaviis and colleagues. This study therefore supports the validity and reproducibility of their classification method for the ultrasonographic evaluation of children with OSD. This is only the first step, and further assessment of this classification is still required to elucidate its clinical as well as its prognostic value.     

Tibial tuberosity avulsion-fracture associated with complete distal rupture of the patellar tendon: A case report and review of literature

BACKGROUNDFew cases of avulsion fractures of the tibial tuberosity with simultaneous rupture of the patellar tendon have been reported in the literature. Therefore, its mechanism and incidence have not been determined conclusively. This type of fracture is considered a serious injury that requires prompt diagnosis and early surgical repair. There is no therapeutic algorithm or standard method of treatment due to the infrequency of the injury. In this case report, we conducted an exhaustive review and synthesis of the existing literature including all previously reported cases.CASE SUMMARYWe present a 16-year-old male soccer player with a case of a tibial tuberosity fracture with distal avulsion of the patellar tendon 5 d prior to surgical treatment. The patient presented with a loss of the extensor mechanism of the knee, edema, the inability to walk, and pain. X-rays showed a high patella and a 180-degree avulsion of the tibial tuberosity. The diagnosis was confirmed by magnetic resonance imaging and computed tomography. The patient underwent open reduction and internal fixation of the fracture with a cannulated screw and washer as well as patellar tendon repair with two metallic anchors. The rehabilitation protocol consisted of initial immobilization in extension followed by passive mobility and muscle strengthening exercises. The patient demonstrated excellent postoperative outcomes and returned to regular activity without complications.CONCLUSIONThis case presentation and literature review comprise the most relevant clinical, radiographic, and treatment details described in the international literature to date, providing the reader with an overview of this rare condition.     

Hemorrhoidal laser procedure: short- and long-term results from a prospective study

Background

We report the results of 2-year regular use of the hemorrhoidal laser procedure (HeLP) in 97 patients with symptomatic second- to third-grade hemorrhoids with minimal or moderate internal mucosal prolapse.

Methods

Data on duration of the procedure, perioperative complications, postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease (HD) were prospectively collected.

Results

No significant intraoperative complications occurred. The median follow-up was 15 months. Postoperative pain was null in most patients. There were no cases of rectal tenesmus or alteration of defecation habits. Symptoms and HD downgrading reached a “plateau” at 3 to 6 months after the HeLP. At this evaluation, frequency of bleeding, pain, itching, and hemorrhoidal acute syndrome decreased by 76% to 79%. HD grade showed a significant reduction. HD recurrence rate was 5% at 2 years.

Conclusions

Our study demonstrates that the HeLP is a safe, effective, and painless technique for the treatment of symptomatic second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse, ideally suitable as ambulatory treatment.     

关节镜对膝骨性关节炎诊断与治疗——附75例长期随访报告

目的　探讨关节镜对膝骨性关节炎诊断的意义及临床疗效。　方法　回顾分析 1993年 5月～ 1999年 9月采用关节镜治疗不同程度膝骨性关节炎 75例、85膝。对X线片与关节镜下发现进行对比分析。　结果　随访 (16-92 )月 ,平均 5年 ,术后评分平均提高 3 5 7分 ,效果满意 ,无严重并发症。　结论　病变越重 ,X线与关节镜诊断符合率越高 ,反之越低 ;X线对病变部位反映较准确 ,对病变程度反映较差。 5 0 %的中晚期病人合并有半月板病变。合并半月板病变与疗效无关。合并游离体提示疗效较好     

The progression of radiological hand osteoarthritis over ten years: a clinical follow-up study

The natural history of hand osteoarthritis (OA) is poorly understood. The aim of the study was to ascertain the extent and pattern of radiological progression of hand OA over a 10-year period. A follow-up study was carried out on 169 consecutive patients who initially presented with OA of the hands or knees between 1975-1977. Fifty-nine subjects (45 women and 14 men) were recontacted who had paired hand radiographs, a mean of 10 years apart, and were a mean 69 (range 53-86) years old at follow-up. X-rays were scored blind, in three joint areas--distal and proximal interphalangeal joints (DIP and PIP) and first carpo-metacarpal (CMC) joints--using the method of Kellgren and Lawrence (K&L) (0-4), and for osteophytes and narrowing (0-3). Using the highest score for right and left hands (N = 118), K&L changes at the three areas were similar with 47-50% deteriorating, 45-46% unchanged, and 6-8% improving. Similar deterioration was seen when scoring the three joint areas for osteophytes (38-39%) and narrowing (39-48%). New osteophytes appeared in 48% of DIP joints during the 10 years. There was a weak correlation between progression at the DIP and PIP joints, but no relationship between DIP and CMC, or CMC and PIP. Virtually all subjects (97%) deteriorated when the total scores of all joints were calculated. No significant differences were seen between 'severe progressors' and 'minor' in terms of age or body mass index (BMI). A nonsignificant increase in the proportion of knee progressors in the severe progressor hand group was seen and there was a higher rate of baseline DIP OA in knee progressors. These results suggest that the majority of patients with OA of the hands attending a rheumatology outpatients clinic deteriorate radiologically over a 10-year period, about half developing new changes in DIP joints. There were no obvious features distinguishing those with rapid deterioration, although DIP OA appears to be a risk factor for knee progression.     

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis

IntroductionTreatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique.Materials and MethodsPatients affected by mild to moderate hallux valgus deformity and associated to grade 1–2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1–2 OA of the first metatarso-phalangeal joint (MTPJ).Results128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2–11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°.OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up.ConclusionsThe modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients.Level of evidenceIV.     

The Outerbridge-Kashiwagi procedure for osteoarthritis of the elbow: do site and number of loose bodies matter to the outcome?

Twelve consecutive patients were reviewed after having Outerbridge-Kashiwagi procedure of the elbow to ascertain the effect of the site and number of loose bodies on the outcome. Patients were assessed using the Mayo Elbow Performance Score (MEPS) and the Derby Elbow Osteoarthritis Radiography Score (DEORS). Ten men and two women with a mean age of 47 years were followed up for a mean of 3.6 years. Seven patients had two or less loose bodies, and five had more than two loose bodies. Seven had anterior loose bodies alone and five had both anterior and posterior loose bodies. MEPS improved from a mean of 51 to 85 points. Visual analogue pain score improved from a mean of 7.4 to 2.6. DEORS improved from a preoperative mean of 6.5 to 5.3. Number of loose bodies had no significance on the functional outcome; neither had the site. We concluded that the number and site of loose bodies have no prognostic value in predicting the outcome.     

Joint debridement for osteoarthritis of the elbow through a bilateral approach

Principle of the operation There are various surgical procedures for osteoarthritis of the elbow joint, such as, resection arthroplasty, total elbow replacement and joint debridement [2]. The indication for each procedure depends on the activities of the patient as well as the stage of the disease. Resection arthroplasty is indicated for severe osteoarthritis. It provides good mobility and relief of pain but joint instability resulting from this procedure is a defnite disadvantage, especially for the manual laborer. Total elbow replacement is also indicated for severe osteoarthritis or rheumatoid arthritis. It provides relatively good stability of the elbow joint, but there is a possibility of loosening of the implants [1, 3]. Total elbow replacement is therefore also contraindicated for a manual laborer. The principle of the joint debridement is to remove the osteophytes, which restrict elbow motion, and to release the contracted capsule in order to improve joint motion and to decrease pain. This procedure is indicated for moderate to severe osteoarthritis. The best indication for this procedure is osteoarthritis of the elbow in active patients or manual laborers. There have been some reports about the joint debridement procedure in which different approaches were used [4, 5]. Ogino developed a joint debridement procedure through a bilateral approach. A salient feature of this procedure is the preservation of the lateral and medical collateral ligaments.      

Joint debridement for osteoarthritis of the elbow through a bilateral approach

Surgical Principles There are various surgical procedures for osteoarthritis of the elbow joint, such as, resection arthroplasty, total elbow replacement and joint debridement [2]. The indication for each procedure depends on the activities of the patient as well as the stage of the disease. Resection arthroplasty is indicated for severe osteoarthritis. It provides good mobility and relief of pain but joint instability resulting from this procedure is a definite disadvantage, especially for the manual laborer. Total elbow replacement is also indicated for severe osteoarthritis or rheumatoid arthritis. It provides relatively good stability of the elbow joint, but there is a possibility of loosening of the implants [1, 3]. Total elbow replacement is therefore also contraindicated for a manual laborer. The principle of the joint debridement is to remove the osteophytes, which restrict elbow motion, and to release the contracted capsule in order to improve joint motion and to decrease pain. This procedure is indicated for moderate to severe osteoarthritis. The best indication for this procedure is osteoarthritis of the elbow in active patients or manual laborers. There have been some reports about the joint debridement procedure in which different approaches were used [4, 5]. Ogino developed a joint debridement procedure through a bilateral approach. A salient feature of this procedure is the preservation of the lateral and medial collateral ligaments. First published in: Operat. Orthop. Traumatol. 3 (1991), 270–278 (German Edition).     

Congenital penile curvature： long-term results of operative treatment using the plication procedure

Aim: To determine the long-term outcome, effectiveness and patient satisfaction of congenital penile curvature correction by plication of tunica albuginea. Methods: From January 1992 to January 2002, 106 young patients underwent surgical correction of congenital penile curvature by corporeal plication. Indications for operation were difficult or impossible vaginal penetration and cosmetic problems. The technique of corporeal plication consists of placing longitudinal plication sutures of 2-zero braided polyester on the convex side of the curvature until the curvature is corrected when erection is artificially induced. Results of this procedure were obtained by retrospective chart reviews and questionnaires via mail. Long-term follow-up ranged from 11 to 132 (mean 69.3) months and data were available for 68 patients. Results: Penile straightening was excellent in 62 patients (91%) and good with less than 15 degree of residual curvature in 6 patients (9 %). Sixty-seven patients reported no change in erectile rigidity or maintenance postoperatively, while 1 described early detumescence. Shortening of the penis without functional problems was noted by 26 patients (38 %). Thirty-Five patients (51%) reported feeling palpable indurations (suture knots) on the penis. Temporary numbness of glans penis was described in 3 patients. Overall, 60 patients were very satisfied, 6 satisfied, 2 unsatisfied. Conclusion: Corporeal plication is an effective and durable procedure with a high rate of patient satisfaction. (Asian J Androl 2004 Sep; 6: 273-276)     

胫骨高位截骨治疗膝骨性关节炎中长期疗效分析

目的 :分析胫骨高位截骨治疗膝骨性关节炎的中长期疗效。方法 :自2001年1月至2005年12月,采用胫骨高位截骨术治疗45例63膝关节内侧间室骨性关节炎患者,男10例(15膝),女35例(48膝);年龄45~64岁,平均(54.76±5.54)岁。术前常规行膝关节负重正侧位X线检查,准确测量股胫角大小,根据术前股胫角决定胫骨外侧截骨量,手术均在硬膜外麻醉下常规行胫骨高位截骨术,大部分行腓骨中段截骨,部分病例行上胫腓关节松解。术后第2天即行功能锻炼,2周开始无负重下床活动,术后8~10周开始负重。术后第2天、8~10周、半年、1年及以后每年1次拍片复查,对全部病例术前、术后3~5年、术后10~14年采用视觉模拟评分(VAS)、美国特种外科医院膝关节评分(HSS)和美国膝关节协会评分(KSS)评价膝关节疼痛、畸形、功能和运动范围。结果 :43例(61膝)进行了10年及以上的随访,全部患者手术切口Ⅰ期愈合,术后8~10周截骨处均达骨性愈合。术后10~14年HSS评分平均76.24±5.27,优27膝,良25膝,可7膝,差2膝。术前与术后3~5年、术前与术后10~14年VAS、HSS、KSS比较有差异,术后3~5年与术后10~14年各项评分无明显差异。结论:胫骨高位截骨治疗膝骨性关节炎(内侧间室关节炎)只要手术指征掌握适当,术后积极锻炼,其中长期疗效满意。     

发育性髋脱位早期保守治疗后残余半脱位的长期随访

目的 探讨发育性髋脱位(developmental dislocation of the hip,DDH)早期手术干预的时机与指证.方法 纳入2000年1月之前出生,经保守治疗后1年内出现残余半脱位畸形,至生长发育停止(髋臼“Y”形软骨闭合)系列骨盆正位X线片完整的DDH患儿共36例48髋.测量髋臼指数(acetabular index,AI)、Reimers指数和CE角,并观察髋臼眉弓形态.采用Severin标准,对末次随访X线片分级,Severin Ⅰ、Ⅱ级为优良,SeverinⅢ、Ⅳ级为中差,分析两组患儿在随访过程中系列X线片各指标的改变.结果 闭合复位时平均年龄1.6岁,末次随访时平均年龄13.8岁,最终18髋(37％,18/48)为Severin Ⅰ、Ⅱ级,30髋(63％,30/48)为SeverinⅢ、Ⅳ级.两组患儿3～4岁时Reimers指数(34.4％±4.5％和43.0％±4.6％)的差异有统计学意义,4～5岁时Reimers指数(29.3％±7.2％和40.0％±6.2％)及CE角(21.0°±5.5°和10.6°±5.2°)的差异均有统计学意义.3～4岁时Reimers指数＞38％(18/18,100％)、4～5岁时Reimers指数＞33％(26/30,87％)的患儿最终为SeverinⅢ、Ⅳ级;4～5岁时Reimers指数＞33％且眉弓向上倾斜(26/26,100％)的患儿最终为SeverinⅢ、Ⅳ级.结论 患儿3～4岁时Reimers指数＞38％、4～5岁时Reimers指数＞33％、眉弓向上倾斜,明显提示远期Seveing分级为Ⅲ、Ⅳ级,应考虑手术矫正,以避免和预防成年后早发性骨关节炎的发生.     

Prevalence of symptomatic hip and knee osteoarthritis: a two-phase population-based survey

Objective

Osteoarthritis (OA) epidemiologic data are scarce in Europe. To estimate the prevalence of symptomatic knee and hip OA in a multiregional sample in France.

Design

A two-phase population-based survey was conducted in six regions in 2007–2009. On initial phone contact using random-digit dialing, subjects 40–75 years old were screened with a validated questionnaire. Subjects screened positive were invited for ascertainment: physical examination and hip and/or knee radiography (Kellgren–Lawrence grade ≥ 2). Multiple imputation for data missing not-at-random was used to account for refusals.

Results

Of 63,232 homes contacted, 27,632 were eligible, 9621 subjects screened positive, 3707 participated fully in the ascertainment phase, and 1010 had symptomatic OA: 317 hip, 756 knee. Hip OA prevalence according to age class ranged from 0.9% to 3.9% for men and 0.7–5.1% for women. Knee OA ranged from 2.1% to 10.1% for men and 1.6–14.9% for women. Both differed by geographical region. The hip and knee standardized prevalence was 1.9% and 4.7% for men and 2.5% and 6.6% for women, respectively.

Conclusions

This confirmed the feasibility of using a screening questionnaire for eliciting population-based estimates of OA. In France, it increases with age and is greater among women above the age of 50. The geographical disparity of hip and knee OA parallels the distribution of obesity.Study registration ID number 906297 at http://www.clinicaltrials.gov/.