Surgical correction of medial subluxation of the patella.

We evaluated the results of a surgical procedure to correct medial subluxation of the patella in 63 patients (65 knees), most of whom had undergone a lateral retinacular release. We performed a direct repair or a reconstruction of the lateral patellotibial ligament using locally available tissue such as strips of iliotibial band or patellar tendon. Followup averaged 53.7 months (range, 24 to 99). Outcome was based on the examiner's inability to clinically reproduce the patient's painful medial subluxation and on the patient's general impression of his or her improved functional status. Forty-four patients (68%) reported improvement in their functional levels and 49 (75%) reported that they were subjectively improved by the procedure. Overall, 50 patients (80%) had a rating of good or excellent. Six knees required a second surgical reconstruction because of failure to improve or because of a reinjury. Analysis of overall clinical outcome revealed no significant relationships based on the patient's age at the time of the initial procedure, sex, or length of followup (P > 0.10). Reconstitution of the lateral patellotibial ligament effectively corrected medial subluxation of the patella and long-term results of this salvage procedure were satisfactory.

Complications of extensor mechanism surgery for patellar malalignment.

This review focuses on the complications of extensor mechanism surgery for symptomatic patellar malalignment and ways to avoid those complications. We combined a review of new and referred patients who had complications resulting from extensor mechanism surgery with a review of selected literature specifically addressing similar complications. By studying the pathologic anatomy at the time of arthrotomy, it was possible in many cases to determine the causes of adverse outcomes with this type of surgery. The complications of extensor mechanism surgery can be avoided by performing a thorough preoperative evaluation, determining each component of the malalignment, tailoring the procedure to correct each patient's unique pathomechanics, and respecting the functional anatomy of the extensor mechanism.

The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up.

Forty-one of fifty patients (fifty knees) who had had a repair of an acute tear of the medial ligaments, a procedure in which repair of the posterior oblique ligament and the semimembranosus complex was emphasized, were re-evaluated after an average duration of follow-up of twenty-two years (range, eighteen to thirty years). The ages of the patients at the time of the injury had ranged from fifteen to twenty-one years. In twenty-four of the forty-one knees, the anterior cruciate ligament had been torn. In seventeen of these knees, the torn ligament had been debrided; in six others, which had had avulsion of a bone fragment or a terminal tear, the ligament had been repaired with absorbable sutures; and in the remaining knee, the repaired anterior cruciate ligament had been augmented. Four patients had had a pes anserinus transfer to supplement the medial repair. The medial meniscus had been intact or repaired in twenty-five of the forty-one knees and had been removed from the remaining sixteen. The lateral meniscus had been retained in thirty-nine knees and removed from two. Postoperatively, all knees had been immobilized for six weeks in 60 degrees of flexion by means of a plaster cast. This had not caused lasting loss of motion, persistent muscle atrophy, or clinically demonstrable deterioration of the articular cartilage. In the twenty-four knees that had had a tear of the anterior cruciate ligament, the rates of instability, meniscal injury, and deterioration of the joint had not increased since the time of treatment, compared with those in the knees with an intact ligament, even though repair and augmentation of this ligament had not been performed (except in one patient, in whom it was unsuccessful). Thirty-eight patients had good stability and a normal range of motion, as well as little or no muscle atrophy. Radiographic changes were slight or absent in all but four knees. Most patients had maintained a high level of physical fitness and recreational athletic activity. There were three failures of treatment (7 per cent). This previously described treatment of acute tears of the medial ligaments, with or without an associated tear of the anterior cruciate ligament, provides good long-term results and is still recommended.

Surgical treatment of diffuse pigmented villonodular synovitis of the knee.

Twenty-five cases of diffuse pigmented villonodular synovitis of the knee in 23 patients were reviewed to determine the results of surgical treatment. All the cases met strict histologic criteria for diagnosis. Long-term clinical follow-up data (average, 58 months) were available for all patients. One case for a patient who was treated by marginal excision recurred within one year. All other cases (initial and recurrent) were treated by total synovectomy, preserving the functional integrity of the knee. Proximal extensor realignments were performed in patients in which chronic distention had caused a redundancy of retinacular tissues. Adhesions, an early complication in eight patients, responded well to closed manipulation and did not adversely affect long-term functional outcome. The outcome was excellent in seven and good in 16 the patients. Two of the patients have had recurrences but have not had another operation. Using this technique, the recurrence rate (8%) and morbidity are significantly lower than those reported previously.

Diagnostic features of diffuse pigmented villonodular synovitis of the knee.

Twenty-five cases of diffuse pigmented villonodular synovitis of the knee in 23 patients were reviewed to identify characteristic clinical presentations and histologic findings. All cases met strict histologic criteria for diagnosis. Clinical presentation consisted of insidious and progressive symptoms of significant joint swelling with discomfort, but not isolated pain. On physical examination, a suprapatellar pouch that was markedly distended by either effusion, synovial masses, or both, and a slight flexion posture were the most consistent findings. Aspiration to detect a bloody effusion was unreliable as a diagnostic tool. Pigmentation was absent in 16% of the gross specimens. Histologically, iron deposition was present in all cases and to a moderate or marked degree in most. Fibrosis, hyalinization, and chronic inflammatory changes were present in most, but to a lesser degree. No patient had gross, histologic, or treatment follow-up findings consistent with neoplasia. Attempts to predict clinical outcome based on histologic findings were unrewarding.

The accuracy of the clinical knee examination documented by arthroscopy. A prospective study.

The diagnostic accuracy of the clinical examination for intraarticular injuries of the knee was documented by arthroscopy over a 6-month period. Two-hundred ninety patients (296 knees) were evaluated by history, physical examination, and standard radiographs. Supplemental diagnostic studies included 41 magnetic resonance images, 2 arthrograms, and 1 previous arthroscopy that had been recently performed. Overall, the correct diagnosis was made in 165 knees (56%), an incomplete diagnosis in 92 (31%), and an incorrect diagnosis in 39 (13%). There were only 2 knees (0.07%) with no discernable lesions. When a single lesion was present in the knee, the diagnosis was made correctly in 72% of cases. When more than 2 were discovered, the diagnosis was correct in only 30%. However, all individual lesions were diagnosed with an accuracy of greater than 90%. The lesions most difficult to diagnose were chondral fractures, fibrotic fat pads, tears in the anterior cruciate ligament, and loose bodies. Knees with acute lesions and those with a single diagnosis proved to be significantly easier to diagnose (P < 0.01). The variables that proved to be insignificant were age, sex, magnetic resonance imaging, surgeon, workers' compensation, or pending litigation.

How iliotibial tract injuries of the knee combine with acute anterior cruciate ligament tears to influence abnormal anterior tibial displacement.

A knowledge of the patterns of injury to the components of the iliotibial tract allows a clearer interpretation of motion limits testing in patients with abnormal anterior tibial translation of the knee (anterior cruciate ligament-deficient knees). Eighty-two consecutive patients with acute knee injuries were classified as anteromedial-anterolateral rotatory instability (anterior cruciate ligament-deficient) based on the abnormal motion demonstrated by clinical examination tests for instability. At surgery, injuries to the intraarticular and extraarticular anatomic structures were identified and correlated to the abnormal grades of motion demonstrated by the knee motion limits examination. Tears of the anterior cruciate ligament occurred in 80 (98%) of the knees. However, the grade of abnormal motion demonstrated by the Lachman and pivot shift tests was quite variable. This variation did not correlate statistically with anterior cruciate ligament tears. Injuries to the anatomic components of the iliotibial tract were confirmed in 76 (93%) of the knees. These injuries correlated highly with variations in grades of abnormal motion detected by the following tests: lateral joint line opening at 30 degrees (r2 = 0.05); Lachman test (r2 = 0.08); pivot shift (r2 = 0.16); and anterior translation at 90 degrees of flexion (r2 = 0.34). Thus, injuries to the components of the iliotibial tract are thought to contribute to the variation in grades of abnormal motion observed in this complex subgroup of anterior tibial translation instabilities.

Analysis of subjective knee complaints using visual analog scales.

A questionnaire using a system of visual analog scales was developed for analyzing subjective knee complaints. This system was tested on 117 consecutive patients who had undergone knee surgery and 65 patients at their initial office evaluation of a knee disorder. The validity of and patient affinity for this type of questionnaire was compared with that of three other established subjective evaluation methods. The visual analog scale system was shown to be valid and comparable to other methods while offering several advantages. It brought greater sensitivity and greater statistical power to data collection and analysis by allowing a broader range of responses than did traditional categorical responses. It removed bias that was introduced by examiner questioning, and it allowed graphic temporal comparisons. Most importantly, patient affinity was higher for this type of subjective evaluation than for other methods.

Popliteal cyst: a surgical approach.

Twenty-nine adult patients (30 knees) who failed conservative treatment had surgical excision of a non-rheumatoid cyst. To determine the effectiveness of this surgical procedure, we reviewed the cases of 24 patients (25 knees) who were available for subjective and objective follow up. Twenty of the 25 knees (80%) were rated excellent or good. Three knees had fair results. Two knees continued to have problems and ultimately underwent total knee replacement for degenerative arthritis.

Roentgenographic findings in pigmented villonodular synovitis of the knee.

Twenty-nine cases of pigmented villonodular synovitis (PVS) of the knee in 27 patients were reviewed to determine characteristic roentgenographic findings. All cases met strict histologic criteria for diagnosis. Four cases were localized PVS (LPVS), and 25 cases were diffuse PVS (DPVS). Roentgenographic findings were largely in the soft tissues. Cystic invasion of bone or degenerative changes were rare, although present in some cases. When present in DPVS, these changes were most pronounced in the patellofemoral articular surface. In the cases of DPVS, large posterior tumefactions did not correlate with extraarticular extension. Clinical behavior of PVS was governed more by anatomic site and form of disease than by the severity of histologic or roentgenographic findings.

Patellar subluxation. A recent history.

For 15 years (1955 to 1970), I was plowing "new ground" pretty much by myself. When you plow behind an old mule and hit a stump hole full of cottonmouth moccasins, you have to get on the move in a hurry and figure out some solution to the predicament or you won't get your corn planted. So, I was not treating the overweight, knock-kneed, loose-jointed, teenaged girl, but the young boy or girl who thought that he or she was an athlete and had dreams of being a star. If rehabilitation did not work, then I thought a lateral release, an Elmslie, and nothing short of a full reconstruction would solve the problem. One had to develop as much vastus medialis obliquus power as this dysplastic muscle could generate, had to transfer the strong vastus lateralis to a more central pull, and, with the distal reconstruction, correct any patella alta and Q-angle abnormality. One had to give the knee every possible advantage in order to serve an athlete. As Hippocrates so wisely noted, one needed to study the athlete to know, with appropriate modifications, what is best for every patient, young or old. In the late 1960s and early 1970s, many fine young orthopedists were stimulated by the information of the AAOS postgraduate courses in sports medicine. They, after having gained further through their own experiences, have become the major contributors to our increasing knowledge of the patellofemoral joint, especially in athletes, and many of these fine "young" (now a little older) orthopedists are now the contributors to this issue. They are giving you their experiences, knowledge, and lessons. A close and repeated study of their information must be combined with compassion for your patient. Then, only experience will develop the desired fine tuning.

Miyakawa patellectomy.

A Miyakawa patellectomy was done in seventeen patients (twenty knees) for either osteoarthritis or chondromalacia of the patella, or both, secondary to malfunction of the extensor mechanism. Patients who had had a patellar fracture were not included in the series. The Miyakawa patellectomy realigns the extensor mechanism, with the proper tension, and centers the functional pull of the quadriceps tendon and patellar ligament. A superficial strip of the quadriceps tendon is pulled distally to fill the void that was left by removal of the patella and to maintain proper length. The musculotendinous portions of the vastus lateralis and vastus medialis are advanced over this defect in the midline and are sutured to the quadriceps tendon. The average length of follow-up was 13.8 years (range, 3.6 to 31.7 years). Nineteen of the twenty knees had a good or excellent subjective result and eighteen had a good or excellent objective result. No subsequent surgical treatment was needed for problems that were caused by malfunction of the extensor mechanism of the knee.

Fractures of the posterolateral tibial plateau.

We reviewed the clinical records and operative notes of 28 patients with fractures of the posterolateral tibial plateau seen at our institution from 1949 to 1982. Five of the 28 patients had chronic depressions of the posterolateral tibial plateau after initial treatment elsewhere. All five were disabled because of significant functional instability when the knee was in flexion. There were 23 acute fractures, of which 4 were initially nondisplaced and treated nonoperatively. One nonoperative patient was lost to followup; the remaining three were rated as having had good or excellent results. Nineteen patients had acute depressed fractures and were treated operatively with open reduction, elevation of the depressed area, and bone grafting, with or without internal fixation. All patients treated operatively at the time of injury were seen for followup from 24 to 145 months postoperatively, with a mean followup of 59 months. One patient was lost to followup; the other 18 were rated using both objective and subjective criteria. Seventeen (94%) achieved a final rating of excellent or good; one patient (6%) achieved a rating of fair. We have observed these fractures occurring in a younger population and producing significant disability in activities requiring a stable knee in flexion. The depressed posterolateral tibial plateau fracture is best assessed by AP, lateral, and 45 degrees internal oblique views on radiographic examination. Because of continued disability caused by chronic, depressed fractures of this type, we recommend open reduction and bone grafting in acute cases to eliminate instability in flexion. This procedure produces good or excellent results in most cases.

Medial subluxation of the patella as a complication of lateral retinacular release.

We examined 54 patients (60 knees) referred to us because of their failure to improve, or because of a worsening of their preoperative symptoms, following an arthroscopic lateral retinacular release. Thirty knees developed medial subluxation of the patella postoperatively. This disabling condition is new to us. It is previously unreported as a complication of arthroscopic lateral retinacular release. Anterior knee pain was the only reported preoperative symptom in 14 knees. Sixteen knees had a preoperative diagnosis of lateral patellar subluxation on the basis of a positive apprehension sign only. Eighteen of 30 knees had no surgery of the extensor mechanism other than the arthroscopic lateral release. The remainder additionally underwent varying types and numbers of operations in an attempt to resolve their disability. CAT scan evaluation of three patients who volunteered for the procedure demonstrated severe atrophy and retraction of the vastus lateralis. Loss of this dynamic lateral stabilizer contributed to the medial subluxation of the patella.

Treatment of acute patellar dislocation.

To determine the effectiveness of nonoperative and operative treatment of initial acute patellar dislocation, we reviewed the charts of 399 patients with the diagnosis of an acute dislocation, seen during a 30 year period. One hundred patients (103 knees) met the criteria for inclusion in the study. The average age of the patient at injury was 21.7 years (range, 9 to 72 years). Length of followup averaged 8 years (range, 2 to 26 years). Retrospectively, we divided the patients into two groups, according to the examination of their unaffected knee. Group I (69 knees) showed evidence on examination of congenital abnormality of the extensor mechanism in the unaffected knee, indicating a predisposition to dislocate with less significant trauma. Group II (34 knees) showed no clinically perceptible congenital predisposition to dislocate based on examination of the unaffected knee. In the nonoperatively treated knees in Group I, there was a 52% (28/54) incidence of good or excellent results. The nonoperatively treated knees in Group II had a 75% (15/20) incidence of good or excellent results. Acute dislocation occurred more frequently in males than in females. Recurrence was rarer in patients whose initial dislocation had occurred when they were over 15 years old. Contrary to recently published reports, primary acute traumatic patellar dislocations can be treated with nonoperative therapy with good or excellent results. Initial evaluation should include examination of the uninvolved knee which, if found to have signs of congenital abnormality, would indicate a worse prognosis.

The absent posterior drawer test in some acute posterior cruciate ligament tears of the knee.

Over a 10 year period, 24 of 54 acute PCL tears in cases of straight medial instability demonstrated an absent or an equivocal posterior drawer test. Most of these (22, 91.6%) were contact injuries, and in the 11 cases where the mechanism of injury was known (45.8%), were incurred by a blow to the outer aspect of the leg while the foot was planted. The ACL was normal in 6 of the 24 knees. The abduction stress test at 0 degree extension was severely positive (2+ or more) in 21 of the 24 knees (87.5%). The phenomenon of an absent or equivocal posterior drawer test in the situation of acute straight medial instability is felt to occur when the mechanism of injury does not stress, strain, or tear the arcuate complex. If the PCL tear is not discovered and repaired, repeated stressful activity stretches the arcuate complex, and the chronically unstable knee subsequently presents with a positive posterior drawer test.