Effect of a patellar realignment brace on patellofemoral relationships: Evaluation with kinematic MR imaging

The effect of a newly developed patellar realignment brace was evaluated in 21 patellofemoral joints (19 patients) with patellar subluxation (13 joints with lateral subluxation and eight with medial subluxation) by using active-movement, loaded kinematic magnetic resonance (MR) imaging. Sixteen patellofemoral joints (76%) demonstrated a qualitative correction of or improvement in patellar subluxation (ie, centralization of the patella or a decrease in the displacement of the patella) after application of the brace. Four of the five “failures” occurred in patellofemoral joints that had patella alta and/or dysplastic bone anatomy. These results indicate that the patellar realignment brace was able to counteract patellar subluxation in the majority of patellofemoral joints studied, as shown by active-movement, loaded kinematic MR imaging. This brace appears to be useful for conservative treatment of patients with patellofemoral joint pain secondary to patellar malalignment and maltracking.     

Arthroscopic treatment of anterolateral impingement of the ankle

We studied 31 patients (17 females, 14 males; average age, 34) with more than 2 years of followup who had chronic anterolateral ankle pain following inversion injury. All had failed to respond to at least 2 months of conservative treatment and had negative stress radiographs to rule out instability. On physical examination, tenderness was localized to the anterolateral corner of the talar dome. Magnetic resonance imaging was the most useful diagnostic screening test, showing synovial thickening consistent with impingement in the anterolateral gutter. At an average of 24 months after injury, all patients underwent ankle arthroscopy, which showed proliferative synovitis and fibrotic scar tissue in the lateral gutter, often with associated chondromalacia of the talus. Operative arthroscopic treatment consisted of partial synovectomy with debridement of scar tissue from the lateral gutter. Postoperatively, patients walked with crutches allowing weightbearing as tolerated. Average return to sports was 6 weeks. Histopathologic analysis performed on the resected tissue showed synovial changes consistent with chronic inflammation. Results of treatment after at least 2 year followup were 15 excellent, 11 good, 4 fair, and 1 poor. Since there are several distinct causes of chronic ankle pain, we prefer to call this problem "anterolateral impingement of the ankle" and believe the term "chronic sprain pain" should be discarded.     

Arthroscopic treatment of osteochondral lesions of the distal tibia

BACKGROUND: Osteochondral lesions of the tibia are much less frequent than those of the talus, and treatment guidelines have not been established. We hypothesized that arthroscopic treatment methods used for osteochondral lesion of the talus would also be effective for those of the distal tibia. METHODS: A review of 880 consecutive ankle arthroscopies identified 23 patients (2.6%) with osteochondral lesions of the distal tibia. Four patients were excluded because of concomitant acute ankle fractures requiring open reduction and internal fixation and two were lost to followup, leaving 17 in the study. The mean age was 38 (19 to 71) years. Six (35%) had osteochondral lesions of the tibia and talus; 11 had isolated lesions of the distal tibia. Treatment included excision, curettage, and abrasion arthroplasty in all patients. Five patients had transmalleolar drilling of the lesion, two had microfracture, and two had iliac bone grafting. At last followup, patients were evaluated with a questionnaire, physical examination, and ankle radiographs. RESULTS: Mean followup was 44 (24 to 99) months. Preoperatively, the median American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 52; postoperatively, it was 87. Using the Wilcoxon signed-rank test to compare preoperative and postoperative scores, there was significant improvement in the ankle-hindfoot score postoperatively (p < 0.001). Seven patients had excellent results, seven had good results, one had a fair result, and two had poor results. CONCLUSIONS: Osteochondral lesions of the distal tibia present a challenge to the orthopedic surgeon. Arthroscopic treatment by means of debridement, curettage, abrasion arthroplasty, and, in some patients, transmalleolar drilling, microfracture, or iliac crest bone grafting, resulted in excellent and good results in 14 of 17 patients at medium-term followup.     

Anterior fracture-dislocations of the shoulder: pitfalls in treatment

Fracture-dislocations of the shoulder can present difficulties in treatment. Two cases are described to illustrate the complications that can occur when an inexperienced examiner attempts a closed reduction of a two-part anterior fracture-dislocation of the shoulder. Careful clinical and radiologic evaluation (A-P and transcapular or axillary lateral X-rays) followed by appropriate management can help to prevent these problems from occurring. If there is evidence that the fracture is displaced by manipulation, immediate open reduction and internal fixation are recommended.     

Identifying a motor proficiency barrier for meeting physical activity guidelines in children

Objectives

This study examined the existence of a threshold level (proficiency barrier) of actual motor competence (MC) below which a child is not likely to attain 60 min of moderate-to-vigorous physical activity (MVPA) per day.

Evaluation of patients with persistent symptoms after lateral retinacular release by kinematic magnetic resonance imaging of the patellofemoral joint

The arthroscopic lateral retinacular release is typically performed to treat patellar pain and instability. This procedure was previously considered to be relatively benign with a low associated complication rate. However, a high incidence of medial subluxation of the patella was recently reported in patients with persistent symptoms after lateral retinacular release. Because the use of physical examination criteria may not always be sufficient to assess patellar alignment, 40 patients (43 knees) were evaluated by the newly developed technique of kinematic magnetic resonance imaging of the patellofemoral joint. One (2%) patellofemoral joint had normal patellar alignment, 10 (23%) had lateral subluxation of the patella, 1 (2%) had excessive lateral pressure syndrome, 27 (63%) had medial subluxation of the patella, and 4 (9%) had lateral-to-medial subluxation of the patella. Seventeen of 40 patients (43%) with unilateral arthroscopic lateral retinacular releases had medially subluxated patellae on the unoperated joints. Because patellar malalignment commonly affects bilateral joints, medial subluxation of the patella may have been present before the lateral retinacular release but was not recognized in these patients.     

Arthroscopy--"no-problem surgery". An analysis of complications in two thousand six hundred and forty cases

In a retrospective review of 3,261 arthroscopic procedures on the knee, 2,640 met the criteria for inclusion in this analysis. The patients' ages ranged from eight to eighty-three years. There were 1,541 male and 1,099 female patients. Eight hundred and ninety-five of the injuries were work-related. A tourniquet was used in 1,175 procedures and the average tourniquet time was thirty minutes. There were 216 complications over-all (8.2 per cent), 126 being designated as major and ninety-seven, as minor. The major complications that were evaluated were infections, hemarthrosis, adhesions, effusions, cardiovascular, neurological, reflex sympathetic dystrophy, and instrument breakage, and the minor complications were difficulties with wound-healing and ecchymosis. Chi-square analysis showed the following factors to be significant (p less than 0.05). Patients with an industrial injury had a higher rate of neurological complications and reflex sympathetic dystrophy. Diagnostic arthroscopy had the lowest over-all complication rate. Partial medical meniscectomy was associated with a higher over-all complication rate and the highest hemarthrosis rate, and partial lateral meniscectomy was associated with the highest rate of instrument breakage. Abrasion arthroplasty had the highest rate of complications of wound-healing, and subcutaneous lateral release was associated with the most adhesions. The sex of the patient and whether or not a tourniquet had been used had no effect on complications. The experience of the surgeon with arthroscopic procedures also had no correlation with the complication rate. Multiple regression analysis showed that two factors (age and, if a tourniquet was used, the tourniquet time) were dominant predictors of complications. From these data, a model was devised for predicting which patients were at risk for complications and their relative levels of risk. Certain complications may be preventable, and for others the risk factors can be reduced. The high-risk patients in our series were fifty years old or older and had a tourniquet time of sixty minutes or longer.     

Arthroscopic "second look" at the GORE-TEX ligament

We performed an arthroscopic "second look" in 21 knees (20 patients) that had arthroscopic implantation of the GORE-TEX prosthesis for chronic ACL insufficiency. Arthroscopy was done on eight knees at the time of screw removal, eight for knee pain, two for giving way, and three for recurrent effusions. The degree of synovial joint reaction, graft synovial ingrowth, and graft rupture was graded. Microscopic examination was carried out on all biopsies of the GORE-TEX ligament. The average patient age was 30 years and the average time interval from original implantation to second look was 11 months. The GORE-TEX was intact in 11 knees, 10% ruptured in 6, and completely ruptured in 4. There was no correlation between number of GORE-TEX strands ruptured and synovial reaction. No particles of the graft were noted in the synovium if the implant was intact, but particles were noted with graft rupture. We conclude that the intact GORE-TEX ligament is an inert substance and does not cause significant joint reaction. Impingement in the intercondylar notch appeared to be the most common cause of graft failure. Further study is critical to determine the natural history of the GORE-TEX ligament and the knees' response to this prosthetic device.