Quadriceps muscle contraction causes medial patellofemoral ligament elongation by intermeshed fibers of vastus medialis oblique muscle.

The first aim of this study was to compare the medial patellofemoral length between contracted and relaxed quadriceps muscle and second to assess the importance of the intermeshed vastus medialis oblique fibers. After a priori power analysis (α = 0.05, power [1-ß] = 0.95), 35 healthy males aged 18-30 were prospectively examined with a 3.0-T magnetic resonance imaging (MRI) scanner in 10-15° of knee flexion. Two axial MRI sequences (25 s each) were made with relaxed and contracted quadriceps. Two blinded, independent raters measured twice medial patellofemoral ligament length (curved line) and attachment-to-attachment length (straight line). Mean medial patellofemoral ligament length and attachment-to-attachment length with relaxed quadriceps was: 65.5 mm (SD = 3.7), 59.7 mm (SD = 3.6), and after contraction, it increased to 68.7 mm (SD = 5.3), 61.2 mm (SD = 4.7); p < 0.01 and <0.001, respectively. Intraclass correlation coefficients for intra- and inter-rater reliabilities ranged from 0.55 (moderate) to 0.97 (excellent). Mean medial patellofemoral ligament length elongation after quadriceps contraction was significantly greater (3.2 mm, SD = 3.9) than mean attachment-to-attachment length elongation (1.6 mm, SD = 2.8); p < 0.001. Contraction of quadriceps muscle causes elongation of the medial patellofemoral ligament to the extent greater than the elongation of distance between its attachments. This confirms that medial patellofemoral ligament elongation after quadriceps contraction results not only from movement of its patellar attachment but also directly from intermeshed vastus medialis oblique fibers pulling medial patellofemoral ligament in a different direction creating a bow-like construct in agreement with the "pull-and-guide mechanism" proposed in the literature.

The knee function of the soccer players after ACLR is comparable with non-injured controls: A case-control study.

PURPOSE: Many studies report a high primary success rate of ACL reconstruction (ACLR), with an increased risk of decline in knee performance correlating with the time passed since surgery. Only one study has compared male soccer players after ACLR to a matched control group of uninjured players in terms of their return to sport and performance. The purpose of this cross-sectional case-control study was to determine the knee performance between soccer players after ACLR and control group matched by age, sex, and professional experience. METHODS: All the male professional soccer players aged 18-36 years at the time of injury, who sustained an ACL tear while playing league soccer in Poland between January 2008 and December 2011 were contacted and compared with age and experience-matched healthy control group selected from professional football players. KOOS, IKDC-2000, Lysholm and SF-36 scales were used for comparison. RESULTS: The average follow-up was 7.9 years (range 6-9 years). The ACL-injured soccer players scored significantly lower in IKDC and Lysholm scores compared with the reference group but still were classified as normal knee function in both scales. In all five dimensions of the KOOS and subscales of SF-36 no apparent differences were noted. In all scales in the study group, no correlation was observed between the player's age and follow-up time after ACLR. CONCLUSION: After ACL reconstruction and successful return to professional sport, knee function is as good as uninjured team members in the midterm follow-up. LEVEL OF EVIDENCE: III.

Arthroscopic Complete Posterior Capsulotomy for Knee Flexion Contracture.

Knee flexion contracture is a clinically important complication that can be observed after trauma, after knee surgery, or as a result of osteoarthritis. When it is left untreated, knee shearing forces increase not only in the affected joint but also in the contralateral knee, leading to mechanical overload in both limbs. Conservative management is a first-line treatment option for extension deficits, but when it fails, surgical treatment is necessary. Open as well as arthroscopic techniques focus mainly on an anterior arthrolysis and a posterior capsular release. Until now, posterior capsulotomy involved either a medial posterior capsular release or medial and lateral posterior capsular releases. Our aim is to present the technique of arthroscopic complete posterior capsulotomy for knee flexion contractures.

Long Head Biceps Tendon-Natural Patch for Massive Irreparable Rotator Cuff Tears.

Despite the development in shoulder surgery, massive irreparable rotator cuff tears still remain challenging for orthopaedic surgeons. Many surgical methods are addressed to this kind of pathology, but each of them has its own limitations. We decided to fuse the ideas of superior capsular reconstruction, "GraftJacket" technique, and partial rotator cuff repair. In this way, the technique using the long head biceps tendon simultaneously as a vascularized bridge between rotator cuff remnants and greater tubercle and as a depressor for the humeral head was created. This Technical Note describes the technique.

Histological changes of the acetabular labrum in coxarthrosis: labral degeneration and repair.

INTRODUCTION: The current study was designed to describe types of histological changes within the acetabular labrum in the advanced stages of coxarthrosis, in patients requiring total hip arthroplasty (THA). METHODS: 77 consecutive patients without systemic disorders or prior hip surgery, scheduled for THA with 3 types of coxarthrosis: avascular necrosis (AVN), idiopathic, and dysplastic coxarthrosis were analysed. Patient's data: age, gender, side of the involvement, duration of the symptoms were recorded, and standard anteroposterior (AP) radiographic views of the pelvis were obtained. During THA procedure the acetabular labrum was harvested and examined histologically and immunohistochemically. The mean chondrocytes number and density were calculated using morphometric techniques. RESULTS: In 77 analysed acetabular labra the following histological changes were found: heterogenic matrix, foci of granular matrix breakdown, pseudocysts, intralabral c alcifications, chondrocyte apoptosis, inflammatory reaction with lymphocytes infiltration and macrophages infiltration and vascular proliferation with 2 stages of maturation: endothelial cell formation and fully formed blood vessels. The average chondrocytes density was 478 cells in 1 mm2 and significantly decreased with age. CONCLUSIONS: The acetabular labrum is an important part of the process of degeneration of the hip in osteoarthritis (OA). Vascular formation and cellular infiltration found in the damaged fibrocartilage may represent a labral response to degenerative changes.

BIPARTITE PATELLA IN 35-YEAR-OLD FITNESS INSTRUCTOR: A CASE REPORT.

BACKGROUND AND PURPOSE: The patella plays an important role in knee biomechanics and provides anterior coverage of the knee joint. One to two percent of the population has an anatomical variant of patella called a bipartite patella that usually does not case pain. However, occasionally after injury or overuse during sport it can be a source of anterior knee pain. The purpose of this case report was to present a rare variant of bipartite patella and highlight conservative treatment of this condition. STUDY DESIGN: Case Report. CASE DESCRIPTION: A 35-year-old female patient presented with persistent bilateral non-traumatic anterior knee pain of a six-year duration that was enhanced by strenuous kinds of sport activity. Standard radiographs and MRI revealed the presence of bipartite patella with medial pole cartilage edema bilaterally. Conservative care including physical therapy, extracorporeal shock wave therapy (ESWT), and viscosupplementation was utilized. OUTCOME: After treatment VAS decreased to 0/10 from 5/10 in the left knee and 1/10 from 5/10 in the right knee. The Kujala Scores improved after treatment to 100 and 95 for the left and right knees respectively. The subject returned to full sport activity and work as a fitness instructor without pain and limitations. DISCUSSION: This case describes a rare finding of bilateral medial bipartite patella and the successful use of physical therapy with viscosupplementation in patellar pain caused by bipartite patella. It also supports the use of Extra Corporeal Shock Wave Therapy in bipartite patella pain as a supplement for therapy. LEVEL OF EVIDENCE: 4.

MRI evaluation of the development of intercondylar notch width in children.

PURPOSE: The purpose of this study was to evaluate the development of intercondylar notch width in children using MRI and assesse the relationship between the cruciate ligaments and the width of the intercondylar notch during growth. METHODS: We reviewed MRIs and medical records of 76 children (age range 3.8-16.9) without derangements of the knee. Cases with knee joint instability and/or major trauma were excluded. On a standardized coronal image, measurements of the width of the intercondylar notch, knee, ACL and PCL were performed using image analysis software. The notch width index (NWI), ACL/notch, ACL/knee width, PCL/notch, and PCL/knee width were calculated. RESULTS: NWI showed statistical correlation with age. The highest values were found in the youngest children, and the lowest in the oldest group. While ACL/knee width, and PCL/knee width ratios remained proportional over time, the ACL/notch, and PCL/notch ratios increased with the age of the patient. CONCLUSION: NWI changes with age and decreases from childhood to adolescence. A relative decrease in NWI accounts for an increase in the ACL/notch and PCL/notch ratios with age. Studies about NWI in children should consider age as a cofactor for analysis.

Fractures of the distal humeral metaphyseal-diaphyseal junction in children.

BACKGROUND: To our knowledge, there is no report in the English-language literature of metaphyseal-diaphyseal junction fractures of the distal humerus in children. The purpose of this study was to review our experience with this uncommon fracture. METHODS: Between 1998 and 2004, 422 displaced supracondylar humerus fractures underwent operative reduction and fixation at our institution. A retrospective review of medical records and radiographs revealed that 14 (3.3%) of these fractures occurred at the metaphyseal-diaphyseal junction just proximal to the olecranon fossa. In 8 patients, the fracture line was oblique (group A), and in 6 patients, the fracture line was transverse (group B). RESULTS: Average age at the time of fracture was 4.9 years (range, 1.5-10 years). All patients were treated by closed reduction and Kirschner wire fixation and had at least 1-year follow-up. In group A, operative time for reduction and fixation was significantly increased in comparison to the 408 remaining supracondylar humerus fractures. However, the clinical course in group A was uncomplicated, and no loss of fixation at follow-up was noted. The operative time in group B was even longer. These fractures were more problematic as loss of fixation occurred in 5 of the 6 patients, 4 occurring in the sagittal plane. In addition, multiple complications arose in group B including reoperation, cubitus varus, pin migration, and prolonged loss of motion. CONCLUSION: Metaphyseal-diaphyseal junction fractures of the distal humerus in children are rare but can be problematic. The transverse fracture pattern requires additional attention in the operating room with optimal pin fixation. Close postoperative follow-up is necessary. The oblique fracture pattern, while requiring increased time in the operating room for reduction and fixation, is typically stable with the usual fixation used for supracondylar humerus fractures. In summary, metaphyseal-diaphyseal junction fractures of the distal humerus are uncommon elbow fractures in children that should be differentiated from the more common supracondylar humerus fracture for optimal outcomes. LEVEL OF EVIDENCE: Therapeutic level 4 (case series).

The proximal femoral growth plate in Perthes disease.

We hypothesized the extent of involvement of the proximal femoral growth plate in Perthes disease determined the final radiographic outcome after containment by shelf acetabuloplasty. We retrospectively evaluated the extent of growth plate involvement using a modified version of the method described by Yasuda and Tamura. In our modification, we used only the epiphyseal border for measurements, which was clearly visible as a thin white line, unlike Yasuda and Tamura who used the metaphyseal and epiphyseal borders. We could not clearly demarcate the metaphyseal border in the radiographs of our patient population between 1944 and 1998, which consisted of 69 patients who had surgery at a mean age of 9 years (range, 6.0-14.1 years). From these measurements, we formulated an index termed "growth plate involvement." Radiographic results were classified as described by Stulberg et al A growth plate involvement index less than 0.25 resulted in a good radiographic outcome. We found 93.2% sensitivity and 100% specificity in predicting Stulberg's outcomes. The growth plate involvement index is a reliable and reproducible measurement method and may be used prospectively as a useful prognostic factor to predict radiographic outcomes after containment acetabuloplasty.

Lateral acetabular growth stimulation following a labral support procedure in Legg-Calve-Perthes disease.

BACKGROUND: The main goal of containment treatment in cases of Legg-Calvé-Perthes disease is to prevent hip deformity, which leads to arthritis in adulthood. Recently, the shelf arthroplasty (the labral support procedure) has been proposed as a method of containment. The purpose of the present study was to evaluate growth stimulation of the acetabulum in patients with unilateral Legg-Calvé-Perthes disease by measuring acetabular depth and height following treatment with the labral support procedure. Uninvolved, contralateral hips and hips that were treated with proximal femoral varus osteotomy were used to compare growth. METHODS: Sixty-five consecutive patients with unilateral Legg-Calvé-Perthes disease that had been treated with the labral support procedure (forty-nine) or a proximal femoral varus osteotomy (sixteen) were evaluated on the basis of radiographic and clinical data that had been obtained at the time of surgery as well as at one, three, and five years after surgery. Acetabular dimensions (depth, height, and total depth with shelf) were measured and, to eliminate radiographic magnification error, the data were expressed in ratios between the involved and uninvolved sides. RESULTS: Preoperatively, both surgical groups were comparable. Acetabular depth indexes at the time of surgery were not different between the groups (p = 0.46). At one, three, and five years postoperatively, the mean depth indexes in the labral support group were significantly higher than those in the proximal femoral varus osteotomy group (F = 5.417, p = 0.001), and trend analysis showed a significant quadratic effect over time in the labral support procedure group (F = 13.132, p = 0.001). The acetabular height indexes at the time of surgery were not different between groups and showed 11% to 13% acetabular overgrowth. The acetabular height indexes in both groups remained unchanged at the time of follow-up (F = 2.82, p = 0.1). The total depth index showed decreasing linear trend values over the period studied (F = 35.115, p = 0.001). CONCLUSIONS: Overgrowth of the acetabulum occurs naturally and early in the course of Legg-Calvé-Perthes disease and is more pronounced in terms of height. The labral support procedure induces additional lateral growth of the true acetabulum (excluding the shelf) for three years following surgery, whereas a proximal femoral varus osteotomy does not. Thus, beneficial effects of the labral support procedure are lateral acetabular growth stimulation, prevention of subluxation, and shelf resolution after femoral epiphyseal reossification. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Fractures of the distal tibial metaphysis in children: patterns of injury and results of treatment.

BACKGROUND: Fractures of the tibia are common in children. Fractures of the distal tibial metaphysis have been only described in fracture texts without reference to a peer-reviewed study. The purpose of the present study was to review this fracture pattern and report the results of treatment. METHODS: The medical records and radiographs of children seen at our institution with a fracture of the tibia were reviewed. The patients with fractures of the distal tibial metaphysis who had been followed until healing were included. Fractures of the distal tibial diaphysis, toddler's fractures, and pathologic fractures were excluded. RESULTS: Twenty-six children met these criteria and were included in the study. The mechanism of injury was indirect in 13 fractures and direct in 12 fractures. In 1 patient, the mechanism of injury was unknown. The main cause of indirect injury was fall (11 cases). The most common was the transverse type of fracture (14 patients) followed by the oblique type (11 patients). Only 8 cases were nondisplaced. Valgus angulation was usually associated with a recurvatum deformation, whereas varus angulation was associated with procurvatum angulation. These patterns were present in 14 patients. We observed shorter healing time when the fracture was oblique than transverse. Children with the oblique pattern of injury were younger than children with a transverse fracture. CONCLUSIONS: The patterns of displacement of the distal tibial metaphyseal fractures reported in our study vary from those presented in textbooks. Distal tibial metaphyseal fractures can present with 2 types of displacement: valgus recurvatum and varus procurvatum. Fractures of the fibula always present with the same pattern as the tibia. Primary union of the distal tibial metaphyseal fracture may be expected in all cases regardless of the type of fracture, age, and gender.