The Variation of the Patellar Height in Total Knee Arthroplasties and its Relationship with the Replacement or not of the Patella / Variação da altura patelar nas artroplastias totais do joelho e sua relação com a substituição ou não da patela

Abstract Objective To compare the measurement of patellar height in the pre- and postoperative period of total knee arthroplasties (TKAs) and its variation in patients with and without patellar replacement. Methods Retrospective evaluation of radiographs of patients submitted to TKA between 2014 and 2020. Profile radiographs were evaluated using the modified Caton-Deschamps patellar height index, comparing the pre- and postoperative measurements of 90 patients, with a total of 100 knees. Next, two groups were compared with a different surgical technique, considering the replacement or not of the patella. All patients who had x-rays evaluated had indication of TKA by osteoarthrosis without previous procedures that could interfere at patellar height. Results The statistical analysis showed a statistically significant difference, with the preoperative index superior to the postoperative rate, evidencing an overall decrease in patellar height. The Caton-Deschamps index modified for mean preoperative TKA was 1.41 (±0.25), and it was 1.31 (± 0.25), p< 0.001for postoperative TKA. No significant difference was found in the variation of this index when comparing the groups with and without patellar replacement. The mean difference of the index in the group without patella was 0.11, and 0.08 in the group with patella, and this difference was considered nonsignificant, p= 0.510. Conclusion We can conclude that patellar height had significant variation in the total group, with reduction of patellar height in the postoperative period. However, the height did not vary significantly between the postoperative groups with and without patellar replacement, regardless of the choice of the surgeon.

Resumo Objetivo Comparar a medida da altura patelar no pré- e pós-operatório das artroplastias totais do joelho (ATJs) e sua variação nos pacientes com e sem substituição patelar. Métodos Avaliação retrospectiva de radiografias de pacientes submetidos a ATJ entre 2014 e 2020. Foi feita a avaliação de radiografias em perfil, usando o índice de altura patelar de Caton-Deschamps modificado, comparando as medidas do pré- e pós-operatório de 90 pacientes, totalizando 100 joelhos. A seguir, foi feita a comparação de dois grupos, com técnica cirúrgica distinta, considerando a substituição ou não da patela. Todos os pacientes que tiveram radiografias avaliadas tiveram indicação de ATJ por osteoartrose sem procedimentos prévios que pudessem interferir na altura patelar. Resultados A análise estatística demonstrou uma diferença estatisticamente significativa, sendo o índice pré-operatório superior ao pós-operatório; evidenciando um abaixamento global da altura patelar. O índice Caton-Deschamps modificado para ATJ pré-operatório médio foi de 1,41 (±0,25), e o pós foi de 1,31 (±0,25), p< 0,001. Não foi encontrada diferença significativa na variação deste índice quando comparados os grupos com e sem substituição patelar. A diferença média do índice no grupo sem patela foi de 0,11 e no grupo com patela foi de 0,08, sendo esta diferença considerada não significativa, p= 0,510. Conclusão Podemos concluir que a altura patelar teve variação significativa no grupo total, com redução da altura patelar no pós-operatório. Entretanto, a altura não variou de forma significativa entre os grupos pós-operatórios com e sem substituição patelar, independentemente da opção do cirurgião.

Impact of asymptomatic genu recurvatum on patellar mobility in young males / Impacto do genu recurvatum assintomático na mobilidade patelar em jovens do sexo masculino

BACKGROUND: Genu recurvatum is one of the most commonly presented lower extremity postural malalignments in individuals. Though genu recurvatum and its impact on impaired knee proprioception, anterior cruciate injuries and posterior soft tissue dysfunctions are reported, its association with patellar mobility is scarcely reported and warrants exploration. OBJECTIVES: To evaluate the medial and lateral patellar mobility differences in adult young males with genu recurvatum and normal knee alignment. METHODS: The ethical approval for this cross-sectional study protocol was obtained and the study was conducted in Research Department of Alva's College of Physiotherapy and Research Centre, Moodubidire, DK, Karnataka, India. The study participants were recruited through an institutional-based musculoskeletal and sports clinic. The estimated sample size for this study was 174. A total of 87 young males with genu recurvatum and 87 young males with normal knee alignment fulfilling the selection criteria were enrolled in two groups. Participants' knee joint was examined by an assessor and individuals with > 5° knee hyperextension were assigned to genu recurvatum group, and individuals with knee extension < 5° from neutral were assigned to the normal knee alignment group. Further, the patellar glide test was performed to examine the presence of patellar hypermobility in both groups. RESULTS: The mean age of the participants in genu recurvatum and normal knee alignment group was 22.04 + 1.860 and 21.91 + 1.869, respectively. A significant higher proportion (86.2%) of participants with genu recurvatum identified with patellar hypermobility compared to normal knee alignment. Within the genu recurvatum subjects, 66.66& and 19.54% were observed to have medial and lateral patellar hypermobility. The odds for occurrence of patellar hypermobility in genu recurvatum was estimated to be 13.007 (95%, CI, 5.481 ­ 30.866), respectively. CONCLUSION: The study result suggests that medial patellar hypermobility is more common in individuals with genu recurvatum. Further study investigating on the mechanism contributing towards medial patellar mobility in genu recurvatum populations could validate the present study findings.

INTRODUÇÃO: Genu recurvatum é um dos desalinhamento posturais dos membros inferiores mais comumente apresentado em indivíduos. Embora o genu recurvatum e seu impacto na propriocepção prejudicada do joelho, lesões cruzadas anteriores e disfunções dos tecidos moles posteriores sejam relatados, sua associação com a mobilidade patelar é pouco relatada e merece exploração. OBJETIVOS: Avaliar as diferenças de mobilidade patelar medial e lateral em homens adultos do sexo masculino com genu recurvatum e alinhamento normal do joelho. MÉTODOS: O protocolo do estudo foi explicado e a aprovação ética para o protocolo do estudo foi obtida e o estudo foi conduzido no Departamento de Pesquisa do Alva's College of Physiotherapy and Research Centre, Moodubidire, DK, Karnataka, India. Os participantes do estudo foram recrutados por meio de clínica musculoesquelética e esportiva de base institucional. O tamanho estimado da amostra para este estudo foi de 174. Um total de 87 jovens do sexo masculino com genu recurvatum e 87 jovens do sexo masculino com alinhamento normal do joelho foram incluídos em dois grupos. A articulação do joelho dos participantes foi examinada por um avaliador e os indivíduos com hiperextensão do joelho > 5° foram designados para o grupo Genu recurvatum, e os indivíduos com extensão do joelho < 5° do neutro foram designados para o grupo de alinhamento normal do joelho. Além disso, o teste de deslizamento patelar foi realizado para examinar a presença de hipermobilidade patelar. RESULTADOS: A média de idade dos participantes do grupo genu recurvatum e alinhamento normal do joelho foi 22,04 + e 21,91 + 1,869, respectivamente. Uma proporção significativamente maior (86,2%) de participantes com genu recurvatum identificados com hipermobilidade patelar em comparação com indivíduos com alinhamento normal do joelho. Entre os indivíduos com genu recurvatum, observou-se que 66,66% e 19,54% apresentavam hipermobilidade patelar medial e lateral. Entre aqueles com alinhamento normal do joelho, 44,83% apresentaram hipermobilidade patelar. A razão de chances para ocorrência de hipermobilidade patelar no genu recurvatum foi estimada em 13,007 (95%, IC, 5,481 ­ 30,866), respectivamente. CONCLUSÃO: O resultado do estudo sugere que a hipermobilidade patelar medial é mais comum em indivíduos com genu recurvatum. Um estudo mais aprofundado que investigue o mecanismo detalhado que contribui para a mobilidade patelar medial em populações de genu recurvatum poderia validar os resultados do presente estudo.

Double-pulley combined with suture bridge technique for fixation of comminuted fractures of distal patella pole / 中国骨伤

OBJECTIVE@#To investigate the clinical effect of double pulley combined with suture bridge in the treatment of comminuted fracture of the lower pole of the patella.@*METHODS@#From January 2018 to June 2020, 15 patients with comminuted fracture of the lower pole of the patella were treated with double pulley and suture bridge technology, including 9 males and 6 females, aged 28 to 68 years old with an average of (42.4±9.6) years old. All patients had obvious knee joint pain and limited movement after injury. All knee joints were examined by X-ray and CT, which confirmed that they were all comminuted fractures at the lower level of the patella. After operation, X-ray films of the knee joint were taken regularly to understand the fracture healing, the Insall Salvati index was measure, the range of motion of the joint was recorded, and the function of the knee joint was evaluateed by the Bostman scoring system.@*RESULTS@#All the 15 patients were followed up for 7 to 24 months with an average of (11.4±4.2) months, and there was no obvious anterior knee pain. At the last follow-up, the knee joint range of motion of the affected limb was 105° to 140° with an average of (128.5±12.8) °, and the Insall Salvati index was 0.79 to 1.12 with an average of (0.92±0.18). The X-ray film showed that the patella was bone healing, and no anchor fell off, broken, or displaced fracture block was found. Bostman patellar fracture function score was 27.85±2.06, 13 cases were excellent, 2 cases were good.@*CONCLUSION@#Double pulley technique combined with suture bridge technique is reliable for reduction and fixation of comminuted fracture of the lower pole of patella, and patients can start functional exercise early after operation.

Effectiveness of suture anchor fixation combined with Nice knot strapping via longitudinal patellar drilling in treatment of patellar inferior pole fracture / 中国修复重建外科杂志

OBJECTIVE@#To investigate effectiveness of suture anchor fixation combined with Nice knot strapping via longitudinal patellar drilling in the treatment of patellar inferior pole fractures.@*METHODS@#A clinical data of 37 patients with unilateral patellar inferior pole fracture who met the selection criteria between June 2017 and June 2021 was retrospectively analyzed. Among them, 17 cases were treated with the suture anchor fixation combined with Nice knot strapping via longitudinal patellar drilling (group A), and 20 cases were treated with the traditional Kirschner wire tension band technique (group B). There was no significant difference in terms of gender, age, body mass index, fracture side, combined medical disease, and preoperative hemoglobin between the two groups ( P>0.05). Operation time, intraoperative blood loss, postoperative complications, fracture healing time, knee range of motion, and knee function Bostman score (range of motion, pain, daily work, muscle atrophy, walking aids, knee effusion, soft leg, and stair climbing) and grading were recorded in both groups at last follow-up.@*RESULTS@#There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). All incisions healed by first intention. All patients were followed up 1-2 years, with an average of 1.7 years. X-ray films reexamination showed that all fractures in group A healed, while 2 cases in group B did not heal. There was no significant difference in bone healing time between the two groups ( P>0.05). At last follow-up, the knee range of motion, the range of motion score of Bostman score, total score and effectiveness grading in group A were significantly better than those in group B ( P<0.05). There was no significant difference in the other items of Bostman scores between the two groups ( P>0.05). During follow-up, 2 cases of internal fixation failure and 1 case of internal fixator irritation occurred in group B, and no complication related to internal fixation occurred in group A. The occurrence of complications was significantly lower in group A than in group B ( P<0.05).@*CONCLUSION@#Compared with the traditional Kirschner wire tension band technique, the suture anchor combined with Nice knot strapping via longitudinal patellar drilling for the patellar inferior pole fractures has the advantages of simple operation, reliable fixation, early flexion and extension activity, and better functional recovery of knee joint.

Reemplazar o no la patela. ¿Cuándo y por qué? / Replace or not the patella. When and why?

Cambiar, o no, la patela ha sido motivo de controversia durante muchos años. Las complicaciones asociadas al aparato extensor y el dolor anterior de rodilla representan un problema recurrente en la cirugía protésica de rodilla. En prótesis total de rodilla (PTR) nos encontramos con tres principales posibilidades: siempre cambiar la patela, nunca cambiarla, o hacer un recambio selectivo dependiendo de las características del paciente. En caso de no realizar recambio, se han descripto procedimientos asociados como la pateloplastia o la denervación de la patela. Y los autores que postulan recambio selectivo han evidenciado diversos factores que ayudarían a tomar la decisión, tales como el índice de masa corporal, grado de artrosis, edad, o anatomía patelar, entre otros. Existe una vasta cantidad de publicaciones científicas en torno al recambio patelar. En esta revisión de la literatura se discutirá qué dice la evidencia respecto de las opciones descriptas (recambio selectivo, siempre o nunca) y se concluirá con la opinión de los autores sobre lo más adecuado según la evidencia

Whether to change the patella, or not, has been a matter of controversy for many years. Complications associated with the extensor apparatus and anterior knee pain represent a recurring problem in knee replacement surgery.In total knee prosthesis (TKP) we find three main possibilities: always change the patella, never change it, or make a selective replacement depending on the patient characteristics. If replacement is not performed, associated procedures such as patelloplasty or patella denervation have been described. And the authors who postulate selective replacement have evidenced various factors that would help to make the decision, such as: body mass index, osteoarthritis degree, age, or patellar anatomy, among others.There is a vast number of scientific publications on patellar turnover. In this review of the literature, we will discuss what the evidence says regarding the options described (selective replacement, always or never) and it will conclude with the opinion of the authors on what is most appropriate according to the evidence

Uso de placa malla en el manejo de fracturas conminutas de patela: reporte de caso / Use of mesh plate for the treatment of comminuted patellar fractures: case report

OBJETIVOS Describir la técnica quirúrgica para el uso de placa malla en un caso de fractura conminuta de patela y sus resultados en el seguimiento a mediano plazo. MATERIALES Y MÉTODOS Presentamos un caso de fractura conminuta de patela manejada con el uso de una placa malla y un tornillo canulado asociado, evitando de esta forma la patelectomía parcial y sus posibles complicaciones. RESULTADOS El paciente presentó una evolución satisfactoria, con rango de movimiento de rodilla completo y en condiciones de alta laboral a los cuatro meses desde la cirugía, sin complicaciones ni reintervenciones. DISCUSIÓN El uso de placas malla permite el manejo de fracturas conminutas de patela preservando stock óseo y restaurando la indemnidad del aparato extensor, con una osteosíntesis estable y poco prominente. Casos en que antiguamente la única alternativa era la patelectomía parcial y reinserción del tendón patelar ahora tienen etas placas como opción de manejo. CONCLUSIÓN El uso de placas malla en fracturas conminutas de patela es una alternativa atractiva por la estabilidad que brindan, la capacidad de reservar stock óseo, y la baja tasa de reintervenciones

OBJETIVE To describe the surgical technique for the use of a mesh plate in a case of comminuted patellar fracture and the mid-term follow up outcomes. MATERIALS AND METHODS We present a case of comminuted patella fracture managed with the use of a mesh plate and an associated cannulated screw, thus avoiding partial patellectomy and its possible complications. RESULTS Four months postoperatively, the patient presented full knee range of motion and could be discharged to return to work, with no complications or reinterventions. DISCUSSION The use of mesh plates enables the management of comminuted patellar fractures preserving bone stock and restoring the extensor mechanism with a stable and little prominent osteosynthesis. Cases which previously would only have been treated by partial patellectomy and patellar tendon reinsertion can be treated with these plates. CONCLUSION The use of mesh plates for comminuted patellar fractures is an attractive option due to their stability, their ability to preserve bone stock, and the low rates of reintervention.

Manejo de fracturas conminutas del polo distal de la patela con asas verticales de alambre: reporte de casos / Management of comminuted fractures of the distal pole of the patela with vertical wire loops: case report

INTRODUCCIÓN Las fracturas conminutas del polo distal de la patela representan un desafío para el cirujano de rodilla, pues no existe un tratamiento estándar que permita una rehabilitación acelerada. Recientemente se han descrito la osteosíntesis y la reinserción del polo distal utilizando asas de alambre verticales. MATERIALES Y MÉTODOS Presentamos dos casos de fractura conminuta del polo distal de la patela resueltos con asas de alambre verticales y modificaciones de esta técnica. RESULTADOS Se realizó osteosíntesis del polo distal de la patela, y se logró una reducción radiográfica satisfactoria, lo que permitió una rehabilitación acelerada, con un rango de movilidad progresivo a tolerancia desde el día siguiente tras la cirugía. Los pacientes lograron recuperar el rango de movimiento completo a los dos y tres meses de operados, evolucionaron satisfactoriamente, sin complicaciones relacionadas a esta técnica y sus variaciones, y recibieron el alta médica tras cuatro meses de la reducción y osteosíntesis. DISCUSIÓN Las técnicas tradicionales para el manejo de fracturas del polo distal implican consideraciones especiales en la rehabilitación y complicaciones asociadas. Se utilizó la técnica de asas de alambres verticales en dos pacientes: en uno de ellos, el procedimiento fue complementado con sutura tipo Krackow; y, en el otro, con una placa para minifragmentos, lo que permitió una rehabilitación acelerada y retorno precoz a sus actividades laborales. CONCLUSIÓN El uso de asas de alambre vertical aparece como una técnica segura, que permite una rehabilitación acelerada y un reintegro laboral precoz.

INTRODUCTION Comminuted fractures of the distal pole of the patella represent a challenge for the knee surgeon, as there is no standard treatment that enables accelerated rehabilitation. Osteosynthesis and reattachment of the distal pole using vertical wire loops has recently been described. MATERIALS AND METHODS We herein present two cases of omminuted fracture of the distal pole of the patella resolved with vertical wire loops and modifications of this technique. RESULTS Osteosynthesis of the distal pole of the patella was performed, achieving a satisfactory radiographic reduction and enabling accelerated rehabilitation, with a progressive range of motion the day after the surgery. The patients achieved full range of motion two and three months after surgery. They progressed satisfactorily, without complications related to this technique and its variations, and were discharged four months after the reduction and osteosynthesis. DISCUSSION The traditional techniques for the management of distal pole fractures involve special considerations regarding rehabilitation and associated complications. The vertical wire loop technique was used in two patients: in one of them, it was supplemented with a Krackow suture; and, in the other, with a mini-fragment plate, which enabled accelerated rehabilitation and early return to work. CONCLUSION The use of vertical wire loops appears to be a safe technique, which enables accelerated rehabilitation and early return to work.

Resuperficialización de la rótula en el reemplazo primario total de rodilla: estudio comparativo a dos años de seguimiento / Patellar resurfacing in primary total knee replacement: A comparative study at two years of follow-up

Objetivo: Comparar los resultados funcionales del reemplazo total de rodilla con resuperficialización de rótula o sin resuperficialización, a los dos años de seguimiento. materiales y métodos: Estudio observacional retrospectivo de grupos comparativos de pacientes con osteoartritis sometidos a un reemplazo total de rodilla primario con resuperficialización de rótula o sin este procedimiento, entre enero de 2014 y diciembre de 2016, en dos centros de Colombia. A todos se les colocó una prótesis cementada Optetrak®. La función se evaluó antes de la cirugía y a los dos años mediante las escalas Knee Society Score (KSS), Hospital for Special Surgery (HSS) y Oxford Knee Score (OKS). Resultados:Se incluyeron 206 reemplazos totales de rodilla: 94 (grupo con resuperficialización) y 112 (grupo sin resuperficialización). La media de la edad en la cohorte de estudio era de 66.9 ± 9.7 años y el 76,7% (n = 155) eran mujeres. El tiempo quirúrgico fue más prolongado en el grupo con resuperficialización (mediana 100 min, RIC 90-110) que en el otro grupo (mediana 85 min, RIC 70-90; p <0,001). Aunque se observó una mejoría funcional antes del reemplazo total de rodilla y después, en ambos grupos, el cambio en el KSS clínico, el KSS funcional y el OKS fue mejor en el grupo con resuperficialización (p <0,05). Conclusiones: La resuperficialización de rótula durante el reemplazo total de rodilla se asoció a mejores resultados funcionales a los dos años. No obstante, los pacientes sin resuperficialización también refirieron una mejoría funcional después del reemplazo total de rodilla. Nivel de Evidencia: III

Objective: To compare the functional outcomes of total knee replacement (TKR) with and without patellar resurfacing at two years of follow-up. materials and methods: We carried out a retrospective observational study of patients with osteoarthritis who had undergone TKR with or without patellar resurfacing between January 2014 and December 2016 in two hospitals in Colombia. All patients received a cemented Exactech Optetrak prosthesis. Function was evaluated before surgery and after two years of follow-up with the Knee Society Score (KSS), Hospital for Special Surgery (HSS) and Oxford Knee Score (OKS). Results: A total of 206 TKRs were included, 94 in the group with resurfacing and 112 in the group without resurfacing. The mean age was 66.9 ± 9.7 years and 76.7% (n = 155) were female. Surgical time was longer in the group with resurfacing with a median of 100 minutes (Interquartile range-IQR: 90-110) compared to 85 minutes in the group without resurfacing (IQR: 70-90), p <0.001). Although functional improvement was observed before and after TKR in both groups, the change in clinical KSS, functional KSS, and OKS scores before and after TKR was better in the resurfacing group (p <0.05). Conclusion: Patellar resurfacing during TKR was associated with better functional outcomes at two years of follow-up. However, patients without resurfacing also reported functional improvement after TKR. Level of Evidence: III

Treatment of comminuted fracture of inferior pole of patella with locking suspension and vertical fixation with three steel wires / 中国骨伤

OBJECTIVE@#To explore the clinical application of lockedge suspension combined with three steel wires vertical fixation in comminuted fracture of inferior pole of patella.@*METHODS@#From August 2016 to May 2019, 23 patients with comminuted fracture of the lower pole of the patella, including 14 males and 9 females, were treated with lockedge suspension combined with three steel wires vertical fixation. The age ranged from 34 to 68 (55.0±1.2) years. One year after operation, the pain and function were evaluated by pain visual analogue scale(VAS) and knee flexion and extension range of motion, and the clinical efficacy was evaluated by Lysholm knee score standard.@*RESULTS@#All 23 patients were followed up for 12 to 14, with a mean of(13.0±0.5) months. One patient had skin irritation by the tail of the steel wire, and the rest had no postoperative complications such as incision infection, internal fixation loosening and fracture displacement. The fractures of 23 patients were healed, and the healing time was 10 to 14 weeks with a mean of(12.0±1.1) weeks. The VAS score decreased from 7.96±0.93 before operation to 0.83±0.65 one year after operation. The range of knee flexion and extension activities increased from(20.30±8.69) ° before operation to 1 year after operation(127.39±6.55) °. Lysholm knee score increased from 18.48±4.00 before operation to 96.09±4.91 one year after operation(P<0.05).@*CONCLUSION@#The treatment of comminuted fracture of the lower pole of patella by lockedge suspension combined with three steel wires vertical fixation has reliable fixation and high fracture healing rate. It can meet the requirements of rapid rehabilitation and functional exercise, and the early clinical effect is satisfactory.

Medial parapatellar soft tissue overlapping suture in total knee arthroplasty for severe osteoarthritis with permanent patellar dislocation: early and mid-term results / 南方医科大学学报

OBJECTIVE@#To evaluate the early and mid-term clinical results of medial parapatellar soft tissue overlapping suture in total knee arthroplasty for treatment of severe osteoarthritis combined with permanent patellar dislocation.@*METHODS@#We retrospectively analyzed the data of 12 patients (12 knees) diagnosed with severe knee osteoarthritis combined with permanent patellar dislocation undergoing total knee arthroplasty with medial parapatellar soft tissue overlapping suture. Knee Society Score (KSS), University of California Los Angeles (UCLA) activity-level rating, Visual Analog Scale (VAS) pain score, and knee range of motion of the patients were assessed before and 2 years after the surgery. Anteroposterior and lateral radiographs of the knee joint, full-length standing radiographs of the lower limbs and patellar axial radiographs were evaluated.@*RESULTS@#The mean Knee Society Score of the patients increased from 34.2±11.1 before surgery to 73.5±6.3 at two years after the surgery (P < 0.001). The UCLA activity-level rating increased from an average of 3.8 ± 0.8 before surgery to 5.8 ± 0.6 at two years postoperatively (P=0.003). The mean VAS pain score decreased from 42.8±6.0 before surgery to 20.1±3.7 (P < 0.001) and the range of motion of the knee joint increased from 74.6±8.9 degrees to 97.5±4.5 degrees at two years (P < 0.001). The radiographs showed no signs of subluxation or dislocation of the patella in all the patients.@*CONCLUSIONS@#Medial parapatellar soft tissue overlapping suture in total knee arthroplasty can achieve good early and mid-term clinical results for treatment of severe osteoarthritis combined with permanent patellar dislocation.

Tumor de células gigantes en rótula manejado con patelectomía / Giant cell tumor in patella managed with patellectomy

Se presenta un caso de gonalgia por causa tumoral en rótula en una paciente femenina. Por el incremento de sintomatología y limitación funcional en corto tiempo, se había programado para biopsia y aplicación de injerto óseo y/o polimetilmetacrilato, pero en el acto quirúrgico fue necesario realizar patelectomía total por el masivo compromiso rotuliano ocasionado por un tumor de células gigantes (TCG). Nivel de Evidencia: V

We present a case of knee pain due to a tumor in the patella in a female patient. To which, due to the increase in symptoms and functional limitation in a short time, a biopsy and application of a bone graft or polymethylmethacrylate had been scheduled, but it was necessary to perform patellectomy due to the massive patellar involvement caused by the GCT. Level of Evidence: V

Manejo no quirúrgico de la artrosis de rodilla: ¿Son efectivos los medicamentos orales complementarios? / Non-surgical management of knee osteoarthritis: are complementary oral medications effective?

La artrosis es una enfermedad progresiva de las articulaciones sinoviales que causa dolor, impotencia funcional, discapacidad, y degeneración progresiva de la articulación. En sus tratamientos, sobre todo en etapas tempranas, existen distintas intervenciones para evitar tanto su desarrollo y progresión como también para lograr un adecuado manejo de los síntomas, y hay tratamientos médicos orales no convencionales con evidencia controvertida. El objetivo de este trabajo es proporcionar una actualización, dirigida a especialistas en Ortopedia y Traumatología, respecto a la evidencia actual sobre las terapias complementarias orales en el tratamiento de la artrosis de rodilla. Se hace referencia a los métodos fármacológicos complementarios más usados y estudiados, mencionando el método de acción y las consecuencias estudiadas sobre la artrosis de rodilla. Se finaliza con una tabla de recomendaciones basada en evidencia actual.

Osteoarthritis (OA) is a progressive disease of the synovial joints that causes pain, functional impairment, disability, and progressive degeneration of the joint. Regarding its treatments, especially in early stages, there are different interventions to avoid its development and progression and also to achieve an adequate management of symptoms, and there are unconventional oral medical treatments with controversial evidence. The objective of the present paper is to provide an update, to specialists in Orthopedics and Traumatology, regarding the current evidence on complementary oral therapies in the treatment of knee osteoarthritis. References are made to the most widely used and studied complementary pharmacological methods, mentioning the method of action and the consequences studied on knee osteoarthritis. The article ends with a table of recommendations based on current evidence.

Tratamiento de la fractura conminuta de patela: ¿existen diferencias entre realizar o no una eversión? / Treatment of comminuted patellar fracture: are there differences between performing or not performing an eversion?

OBJETIVO Comparar los resultados clínicos, funcionales e imagenológicos de dos técnicas quirúrgicas para el manejo de fracturas conminutas de patela: con y sin eversión patelar. MÉTODOS En una serie de casos retrospectivos de fracturas conminutas de patela tratadas en el mismo centro entre 2014 y 2017, con un seguimiento ≥ 3 meses, se hizo una comparación entre el grupo con eversión y el grupo sin eversión. Los criterios de exclusión fueron patelectomía parcial o total, reinserción tendínea, o rehabilitación incompleta. Las variables analizadas fueron edad, sexo, tabaquismo, diabetes mellitus, energía del accidente, tipo de fractura, variables quirúrgicas (banda de tensión, tornillos, alambres, nudos, cerclaje circular), rango de movimiento (RDM) articular postoperatorio, presencia de osteosíntesis sintomática, puntaje de escalas funcionales (de Tegner-Lysholm y de Kujala) al alta definitiva, complicaciones (rigidez articular, infección, trombosis venosa profunda), y variables imagenológicos con tomografías computarizadas pre- y postoperatorias (brecha, desnivel articular > 2 mm, elementos de fijación intraarticular). RESULTADOS En total, 20 de 22 pacientes, 13 con eversión y 7 sin eversión, cumplieron con los criterios de selección. El seguimiento fue de 3 a 12 meses, y no hubo diferencias estadísticamente significativas respecto a las variables demográficas entre ambos grupos, lo cual los hace comparables. Destacaron el tiempo desde el ingreso al alta, con 7 meses para los pacientes con eversión y 5 meses para los sin eversión (p = 0.032), la proporción de pacientes con desnivel articular > 2 mm, con 7.7% para los con eversión y 14.3% para los sin eversión (p = 0.016), y una tendencia a resultados superiores en escalas funcionales para el grupo con eversión. CONCLUSIÓN El tratamiento de fracturas conminutas de patela con eversión parece ser una alternativa viable dados sus resultados imagenológicos y funcionales superiores a los de la técnica habitual.

PURPOSE To compare the clinical, functional and imaging outcomes of two surgical techniques for the treatment of comminuted patellar fractures: with and without eversion. METHODS In a retrospective series of cases of comminuted patellar fractures treated at a single center between 2014 and 2017, with a follow-up 3 months , we performed a comparison between the eversion group and the non-eversion group. The exclusion criteria were partial or total patellectomy, tendon reinsertion, or incomplete rehabilitation. The variables analyzed were age, gender, smoking, diabetes mellitus, the energy of the accident, the fracture type, surgical variables (tension band, screws, wires, knots, circular cerclage), postoperative joint range of motion (ROM), presence of symptomatic osteosynthesis, the scores on the functional scales (of Tegner-Lysholm and of Kujala) at the final discharge, complications (joint stiffness, infection, deep vein thrombosis), and pre- and postoperative computed tomography imaging variables (gap, step-off > 2mm, intra-articular fixation elements). RESULTS In total, 20 out of 22 patients, 13 undegoing eversion and 7 not undergoing eversion, met the selection criteria.. The follow-up ranged from 3 to 12 months, and there were no statistically significant differences regarding the demographic variables between both groups, which makes them comparable. The most remarkable results were the time from admission to final discharge, of 7 months for the patients in the eversion group, and of 5 months for those in the non-eversion group (p » 0.032), the proportion of patients with a step-off > 2 mm, with 7.7% for the eversion group and 14.3% for the non-eversion group (p » 0.016), and a tendency towards higher scores in the functional scales for the eversion group. CONCLUSION The treatment of comminuted patellar fractures with eversion seems to be a viable alternative, given its superior imaging and functional results compared to those of the usual technique.

Algunas especificidades en torno a la rótula baja / Some specificities around the low patella

La rótula baja es una enfermedad infrecuente, de causa congénita o adquirida, caracterizada por dolor en la zona anterior de la rodilla y limitación del movimiento articular. La radiografía simple, en proyección lateral, ayuda al diagnóstico a través de determinadas mediciones; asimismo, el tratamiento conservador no resulta muy exitoso, de ahí que las modalidades quirúrgicas son más empleadas. Debido a la importancia de esta temática y a la escasa información disponible en la bibliografía nacional e internacional, en el presente artículo se comenta brevemente al respecto, con el objetivo de brindar información sobre esta enfermedad para que sirva como guía de trabajo.

The low patella is an uncommon disease, of congenital or acquired cause, characterized by pain in the anterior area of the knee and limitation of the articular movement. The simple x-ray, in lateral projection, helps to make a diagnosis through certain measurements; also, the conservative treatment is not very successful, so that surgical modalities are the most used. Due to the importance of this subject matter and the lack of information available in the national and international bibliography, it is shortly commented in this work, aimed at offering information on this disease so that it serves as working guide.

To Retain or Resurface the Patella in Primary Total Knee Arthroplasty: A Comparative Study / Preservar ou substituir a patela durante a artroplastia total de joelho: Estudo comparativo

Abstract Objective To evaluate and compare clinically and functionally patients undergoing primary total knee arthroplasty (TKA) with preservation or replacement of the patella. Methods In a cross-sectional study, the functional results were evaluated and compared, using the Western Ontario and McMaster Universities (WOMAC) and Lequesne scores, of 158 patients undergoing primary TKA (162 knees); in 81 knees the patella was submitted to arthroplasty and in 81 the joint surface of the patella was preserved. Results No significant differences were identified in terms of the Lequesne score (p = 0.585), global WOMAC score (p = 0.169), nor in terms of its subdivisions regarding stiffness (p = 0.796) and functional capacity (p = 0.190). There was a significant difference only in terms of the subdivision that evaluates pain in the WOMAC score, being lower in the group undergoing patellar arthroplasty (p = 0.036). Conclusion In the present study, there was no difference in functional assessment in patients who underwent or not patellar replacement during primary knee arthroplasty surgery. However, individuals in whom the patella was preserved reported more pain.

Resumo Objetivo Avaliar e comparar clínica e funcionalmente pacientes submetidos a artroplastia total primária do joelho (ATJ) com preservação ou substituição da patela. Métodos Em um estudo transversal, foram avaliados e comparados os resultados funcionais, usando escores de Western Ontario and McMaster Universities (WOMAC, na sigla em inglês) e Lequesne, de 158 pacientes submetidos a artroplastia total primária o joelho (162 joelhos), sendo que em 81 joelhos a patela foi submetidaa artroplastiae em 81 a superfície articular da patela foi preservada. Resultados Não foram identificadas diferenças significativas quanto ao escore de Lequesne (p = 0,585), escore global de WOMAC (p = 0,169), nem quanto às subdivisões deste quanto a rigidez (p = 0,796) e a capacidade funcional (p= 0,190). Evidenciou-se diferença significativa apenas quanto à subdivisão que avalia a dor no escore de WOMAC, sendo menor no grupo submetido a artroplastia patelar (p = 0,036). Conclusão No presente estudo, não houve diferença na avaliação funcional em pacientes submetidos a substituição ou não da patela durante a cirurgia de artroplastia primária do joelho. Entretanto, os indivíduos nos quais a patela foi preservada relataram mais dor.

Update on Patellar Instability / Atualização em instabilidade patelar

Abstract Patellar instability is a multifactorial clinical condition that affects a significant number of patients and occurs due to morphological variations of the joint and patellofemoral alignment. The present literature review study aimed to identify and summarize current concepts on patellar instability, in relation to associated risk factors, diagnostic criteria, and the benefits and risks of conservative and surgical treatments. For this purpose, a search was conducted in the following electronic databases: MEDLINE (via Pubmed), LILACS and Cochrane Library. It is concluded that the accurate diagnosis depends on the detailed clinical evaluation, including the history and possible individual risk factors, as well as imaging exams. The initial treatment of patellar instability is still controversial, and requires the combination of conservative and surgical interventions, taking into consideration both soft tissues and bone structures, the latter being the most common reason for choosing surgical treatment, especially lateral patellar instability.

Resumo A instabilidade patelar é uma condição clínica multifatorial, que acomete um número expressivo de pacientes, ocorrendo devido a variações anatómicas, morfológicas da articulação e do alinhamento patelofemoral. O presente estudo de revisão e atualização da literatura teve como objetivos identificar e sumarizar os conceitos atuais sobre instabilidade patelar em relação aos fatores de risco associados, os critérios diagnósticos e os benefícios e riscos dos tratamentos conservador e cirúrgico. Para tanto, foi realizado um levantamento nas bases de dados eletrónicas MEDLINE (via Pubmed), LILACS e Cochrane Library. Conclui-se que o diagnóstico preciso depende da avaliação clínica detalhada, incluindo o histórico e possíveis fatores de risco individuais, além de exames de imagem. O tratamento inicial da instabilidade patelar é ainda controverso, e requer a combinação de intervenções conservadoras e cirúrgicas, levando em consideração tanto os tecidos moles quanto as estruturas ósseas, sendo estas últimas a razão mais comum para a escolha do tratamento cirúrgico, principalmente instabilidade patelar lateral.

Aloinjerto fresco de rótula y defectos osteocondrales / Fresh patellar allograft and osteochondral defects

Introducción: Las lesiones condrales de la rótula son un reto para el cirujano, principalmente en pacientes jóvenes y activos. La mayoría de los defectos condrales de la rótula son lesiones superficiales y pueden ser manejadas con técnicas de preservación articular; sin embargo, las lesiones profundas pueden requerir otro tipo de manejo. El objetivo de este artículo es comunicar el tratamiento de defectos osteocondrales de la rótula en pacientes jóvenes, mediante la técnica de aloinjerto fresco de donante cadavérico. materiales y métodos: Se seleccionaron pacientes con dolor anterior de rodilla, lesión condral de la rótula grado III-IV y que habían recibido o no algún tipo de manejo médico o quirúrgico. En estos pacientes, se usó un aloinjerto fresco de rótula con el fin de solucionar el cuadro y mejorar la función. Resultados: Todos los pacientes recuperaron la función y los arcos de movilidad, y no refirieron dolor. Se comprobó la integración del aloinjerto fresco al área receptora, sin evidencia de rechazos del tejido o infecciones. Conclusiones: El uso de aloinjerto fresco de rótula para tratar defectos osteocondrales amplios es una téc-nica quirúrgica valiosa, fácil de implementar, que no requiere una curva de aprendizaje extensa y que mejora considerablemente el dolor y la función en pacientes jóvenes. Nivel de Evidencia: IV

Introduction: Chondral lesions of the patella are a challenge for the surgeon, mainly in young and active patients. Most patellar chondral defects are superficial injuries and can be managed with joint preservation techniques; however, deep injuries may require other types of management. The objective of this article is to manage osteochondral defects of the patella in young patients, using the technique of fresh allograft from a cadaveric donor. Materials and methods: Patients with anterior knee pain, with grade III - IV chondral lesion of the patella and who had or had not undergone some type of medical or surgical management were included. They received a fresh patellar allograft that sought to provide a solution and improvement of the functionality. Results: In all cases, recovery of functionality and mobility, absence of pain and integration of the fresh allograft into the recipient area were achieved, without evidence of tissue rejection or infection. Discussion: The use of fresh patellar allograft for the management of wide osteochondral defects is a valuable surgical technique, easy to implement, that does not require a long learning curve and that considerably improves pain and functionality in young patients. Conclusions: The advent of fresh osteochondral grafts allows adequate management and evolution of patients, with the aim of favoring joint preservation and avoiding total knee arthroplasty over time. Level of Evidence: IV

Lesiones tendinosas del aparato extensor de la rodilla: Protocolo de tratamiento y rehabilitación / Tendon injuries of the knee extensor mechanism: Treatment and rehabilitation protocol

Introducción: La rotura del aparato extensor puede ocurrir a nivel óseo o tendinoso; la principal causa es la fractura de rótula, seguida de la rotura del tendón cuadricipital y la rotura del tendón rotuliano. Estas lesiones pueden deberse a traumas directos o indirectos. La rotura tendinosa del aparato extensor es poco frecuente: representa el 3% de todas las lesiones tendinosas. Se presenta con traumatismos relacionados con la actividad diaria, deportiva o asociada a enfermedades sistémicas. materiales y métodos: Presentamos una serie de 22 roturas tendinosas del aparato extensor de la rodilla (8 del tendón cuadricipital [2 bilaterales] y 14 del tendón rotuliano [1 bilateral]), tratadas mediante cirugía, entre junio de 2015 y enero de 2019. Todos los pacientes fueron evaluados inicialmente con radiografías y resonancia magnética. Se empleó la escala de Lysholm para la evaluación funcional posquirúrgica. Resultados: El seguimiento posquirúrgico fue mínimo de un año (rango 12-24); los resultados fueron excelentes en 13 casos, buenos en 7 casos y regulares en 2 casos. Conclusión: La reparación primaria, con sutura transósea de las roturas tendinosas del aparato extensor más cerclaje en 8 como aumento en las lesiones del tendón rotuliano brinda una reconstrucción estable, permite implementar un protocolo posquirúrgico de movilización temprana, y así lograr excelentes resultados funcionales con una tasa baja de complicaciones. Nivel de Evidencia: IV

Background: The rupture of the extensor mechanism can have its origin at bone or tendon level. Its main cause is patellar fracture, followed by quadriceps tendon rupture, and, finally, patellar tendon rupture. These ruptures can be due to direct or indirect trauma. Tendon ruptures of the extensor mechanism are rare, developing with trauma related to the daily routine, sports, or associated systemic diseases. They represent 3% of all tendon injuries. materials and methods: We presented 22 tendon ruptures of the knee extensor mechanism, surgically treated between June 2015 and January 2019, from which eight (8) ruptures were of the quadriceps tendon (2 bilateral) and fourteen (14) of the patellar tendon (1 bilateral). The cases were evaluated using the Lysholm score, radiographs, and MRI. Results: The minimum follow-up was one (1) year. According to the results of those twenty-two (22) surgeries, thirteen (13) cases had excellent results, seven (7) cases were good and two (2) of them were fair. Conclusion: In cases of patellar tendon injury, the primary repair with transosseous suture plus figure-of-eight cerclage as augmentation provides a stable reconstruction, allowing the implementation of an early mobilization post-surgery protocol, thus achieving excellent functional outcomes with low complication levels. Level of Evidence: IV

High tibial osteotomy combined with lateral retinacular release for the treatment of knee varus osteoarthritis with lateral patellar compression syndrome / 中国骨伤

OBJECTIVE@#To investigate the clinical effect of high tibial osteotomy combined with arthroscopic lateral retinacular release in the treatment of knee varus osteoarthritis.@*METHODS@#From October 2017 to April 2019, a retrospective analysis was performed on 43 patients with knee varus osteoarthritis and lateral patellar compression syndrome treated by high tibial osteotomy combined with arthroscopic lateral retinacular release. There were 15 males and 28 females, aged 53 to 72(62.05±5.17) years. The visual analogue scale(VAS), Lysholm, and the knee range of motion were used to evaluate knee pain and functional recovery before operation, 2 weeks, 3 months and 12 months after operation. And the congruence angle (CA), patellar tilt angle (PTA), and femala-tibial angle (FTA) were measured respectively before and 12 months after operation to evaluate the congruence of patellar joint, and the improvement of line of gravity of lower limb.@*RESULTS@#All 43 patients were followed up for more than 12 months, with a follow-up time of 14 to 28 (19.60±4.50) months. The VAS scores decreased from 6.65±0.65 before operation to 2.16±0.95, 0.51±0.77 and 0.33±0.64 at 2 weeks, 3 months and 12 months after operation, and the difference was statistically significant (@*CONCLUSION@#High tibial osteotomy combined with arthroscopic lateral retinacular release can relieve weight-bearing pain in frontal axis and improve the function of knee in sagittal axis.

Finite element analysis on stress concentration improvement in patellofemoral joint by releasing lateral patellar retinaculum with stiletto needle based on the theory of Jinshugu() / 中国骨伤

OBJECTIVE@#To study mechanism of improvement of stress concentration on patellofemoral joint by stiletto needle releasing lateral patellar retinaculum guided by the theory of Jinshugu() and based on the finite element model of knee joint. and to elucidate the biomechanical mechanism of stiletto needle releasing changing patellar trajectory and reducing patellofemoral joint pressure.@*METHODS@#CT data of knee joint from a normal male (aged 29, heighted 171 cm, weighted 58 kg) was selected. Starting with construction of three-dimensional model of knee joint by using finite element software, the finite element model of knee joint with complete tendonand bone structures were established through several steps, such as geometric reconstruction, reverse engineering, meshing, material assignment and loading analysis. The loading condition was set as 500 N load on knee joint, and the average tensile stress of quadriceps femoris tendon was about 200 N. To simulate the release of lateral patellar retinaculum by stiletto needle at 30 and 90 position of knee flexion in finite element model separately, and to compare the improvement of stress concentration of patellofemoral joint by stiletto needle intervention under different knee flexion conditions.@*RESULTS@#The peak stress of patellofemoral joint and tibiofemoral joint decreased after stiletto needle releasing of patellofemoral lateral retinaculum compared with before intervention, which was(1) knee flexion at 30 degrees:patellar cartilage decreased by 0.498 MPa (decreased 9.06%), femoral trochlea decreased by 0.886 MPa(decreased 16.27%);(2) knee flexion at 90 degrees:patellar cartilage decreased by 0.558 MPa (decreased 8.6%), femoral trochlea decreasedby 0.607 MPa (decreased 9.94%).@*CONCLUSION@#Releasing lateral patellofemoral retinaculum with stiletto needle could effectively alleviate the stress concentration of patellofemoral joint and reduce local stress peak value, which it is helpful to improve patellar trajectory and make stress distribution more uniform.