Recurrent atraumatic superior dislocation of the patella: case report and review of the literature.

Recurrent atraumatic superior dislocation of the patella with spontaneous reduction prevented by interlocking osteophytes has not been previously reported. Eight previous case reports were noted in the literature with single episodes of interlocking by osteophytes in a superior dislocation, none with recurrence, and all treated by closed reduction. The presentation of a 60-year-old woman with recurrent atraumatic superior dislocation of the patella on three separate occasions required closed reduction due to interlocking patella and trochlear osteophytes that were preventing spontaneous reduction. Arthroscopic debridement of these osteophytes resulted in no functional limitation or recurrence of dislocation at 28-month follow-up. This case demonstrates successful arthroscopic treatment of this previously unreported condition. In light of the increasingly active aging population with coexistent patellofemoral joint osteoarthritis, this presentation may become more frequent.

Continuous passive motion after total knee arthroplasty.

We established a clinical retrospective study to determine the benefit of continuous passive motion after total knee replacement. Nineteen patients who had continuous passive motion (CPM) after total knee replacement were compared to a control group of 15 patients who did not have CPM. The number of days to discharge was 16 for the CPM group and 20 for the control group. When the patients with complications from CPM were excluded from the CPM group, the average number of days to discharge for the CPM group was 12. The average number of postoperative days before reaching 90 degrees of knee flexion was nine in the CPM group as compared to 16 days in the control group. The average blood loss was not significantly different in the two groups. There were four wound healing complications in the CPM group. All four complications occurred in patients who achieved 90 degrees of knee flexion in less than six days postoperatively. We developed a protocol for maximal use of CPM without significant wound complications after total knee surgery.

Lateral retinacular release in patellofemoral subluxation. Indications, results, and comparison to open patellofemoral reconstruction.

A consecutive series of patients who have undergone arthroscopy and lateral retinacular release for patellofemoral subluxation was evaluated so that the results could be compared to an earlier series of open patellofemoral reconstructions. Of 96 patients, 4 had bilateral releases; therefore, 100 knees were evaluated. The average age was 28 years. Specific symptoms and signs were reviewed. All patients were initially treated conservatively with specific exercises. Failure of the exercise program to improve symptoms significantly, the patient's inability to perform normal daily activities, or expected associated pathology were indications for surgery. The surgical technique consisted of arthroscopy with treatment of associated pathology and lateral retinacular release using the Smillie meniscotome through the inferior lateral portal. The patella could be tilted approximately 90 degrees medially when the release was accomplished. Pain, function, and patellar instability were evaluated preoperatively and postoperatively by signs of tenderness on the retinaculum or bone, patellar mobility, effusion, muscle atrophy, and tone. Range of motion was also evaluated. Average followup was 36 months. When evaluated subjectively by the patients, pain improved from a mean preoperative grade of 3.4 to 1.7 postoperatively, function improved from 3.4 to 1.7, and instability from 3.4 to 1.6. Objective evaluation found that tenderness on the patella improved from a mean preoperative grade of 3.3 to 1.7 postoperatively. Tenderness on the retinaculum improved from 3.2 to 1.7. Patellar mobility improved from 3.3 to 1.7. Effusion dropped from 3.2 preoperatively to 1.5 postoperatively; quadriceps atrophy from a mean preoperative grade of 3.2 to 1.5, and quadriceps tone from 3.2 to 1.6.(ABSTRACT TRUNCATED AT 250 WORDS)

Symptomatic dislocation of the anterior horn of the medial meniscus.

Anteromedial joint line pain of the knee represents both a diagnostic and therapeutic challenge. Dislocation of the anterior horn of the medial meniscus as a cause of anteromedial joint line pain is uncommon. O'Connor has reported this finding on internal and external rotation of the tibia during arthroscopy and Dashefsky has demonstrated a shadow sign associated with dislocating anterior horns. We have noted these findings plus anteromedial femoral condylar articular erosion associated with persistent anteromedial joint line pain in 13 patients. All 13 patients had persistent anteromedial joint line tenderness on physical examination present from 3 months to 3 years prior to surgery. Six of the 13 patients had a click in the knee with activity and only 4 of the 13 patients reported "giving away" episodes. Arthroscopic examination demonstrated a complete anterior horn dislocation of the medial meniscus as described by O'Connor and Dashefsky as well as degeneration of the anteromedial femoral condyle. Definitive treatment was performed in the 13 patients after arthroscopic confirmation of the diagnosis of dislocating anterior horn of the medial meniscus. The first four patients had traditional medial meniscectomies, the next four patients had repair of the anterior horn, and the last five patients had partial resection of the meniscus through the arthroscope. Excellent results occurred in three of four patients with repair of the anterior horn, and four of five patients with partial resection through the arthroscope. The one failure of repair subsequently underwent a complete medial meniscectomy with an excellent result.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of vertebral fractures. A comparison of conventional radiography, conventional tomography, and computed axial tomography.

Thirty patients with acute thoracic, lumbar, or thoracolumbar fractures, dislocations, or fracture-dislocations were evaluated with standard radiographs, conventional polytomography, and computerized axial tomography. The resulting ninety studies were coded, randomized, and independently interpreted by three radiologists. The diagnostic accuracy of the interpretations based on the computerized tomography scans combined with standard radiographs equaled that of the interpretations based on just the tomograms in the evaluation of fractures of posterior elements. In addition, computerized tomography was superior to the other methods in demonstrating impingement on the neural canal as well as injuries to other organ systems. Also, when compared with conventional polytomography, computerized tomography could be completed with less risk to the patient (no changes in position and ten times less radiation). We concluded that computerized tomography should replace conventional polytomography as the initial study to augment standard radiographs in the assessment of thoracic and lumbar fractures. Conventional polytomography should be reserved for patients in whom precise evaluation of the pars interarticularis is deemed necessary.

Undetected genito-urinary dysfunction in vertebral fractures.

Five of fourteen patients admitted with fractures of the thoracic and lumbar vertebrae who had normal rectal tone and sacral sensation were subsequently found to have genito-urinary dysfunction. Four patients had a hypotonic bladder documented by cystometrograms. The other patient was impotent from the time of fracture. Since the genito-urinary dysfunction was not detectable by physical examination, thorough urological evaluations are recommended for all patients with fractures of the lower thoracic and upper lumbar vertebrae, even when rectal tone and sacral sensation are normal.