Anterior Knee Research Articles

Transcutaneous oxygen tension in the anterior skin of the knee after minimal incision total knee arthroplasty

BackgroundDelayed wound healing after total knee arthroplasty (TKA) can lead to devastating complications. The lateral flap is reported to be more hypoxic than the medial flap in conventional TKA. However, the surgical approach significantly affects the cutaneous blood supply. Our hypothesis was that postoperative oxygenation of the skin over the anterior knee would be different in minimal incision TKA. MethodsThis prospective observation study included 21 patients who underwent minimal incision TKA. Transcutaneous oxygen tension (TcPO2) was measured perioperatively at four sites around the midline incision: superio-medial, superio-lateral, inferio-medial, and inferio-lateral. The ratio of the regional TcPO2 to the reference TcPO2 was calculated as the regional perfusion index (RPI). We compared the RPI among four sites and evaluated the association between the RPI and wound healing. ResultsAt all measurement sites, the RPI significantly decreased after surgery (days 1 and 7; p<0.01). On day 7, the RPI at inferio-medial and inferio-lateral sites were significantly lower than superio-medial and superio-lateral sites, respectively (p<0.05). No significant difference between the medial and lateral sites was observed. In three patients, delayed healing was noted at the inferio-lateral wound edge, where the RPI significantly decreased on day 1. ConclusionThe distal part of the wound was significantly more hypoxic than the proximal part in minimal incision TKA. Atraumatic wound edge retraction should be carried out especially in the distal part. Although further investigation is necessary, delayed wound healing is potentially associated with regional skin hypoxia on day 1.

Eminence-Based Medicine Versus Evidence-Based Medicine: Level V Evidence in Sports Medicine

Through extensive survey analysis, we investigated expert opinion in sports medicine. The study had 3 purposes: to provide clinical guidance for cases in which the correct action is not necessarily apparent, to examine expert opinion itself, and to delineate areas of future study. A total of 500 members of the American Medical Society for Sports Medicine and the American Orthopaedic Society for Sports Medicine evaluated a set of 25 statements on unresolved issues in sports medicine. The following 10 statements were deemed false: “It's okay for 12-year-old pitchers to throw curve balls; it's the pitch count that matters”; “Resistance training (‘weight lifting’) should be avoided until physeal closure”; “Jogging during pregnancy is to be avoided”; “At an athletic event, if sideline coverage is offered by an emergency medical technician and athletic trainer, there is little additional benefit from having a physician present”; “Contact sport athletes who sustain a second concussion should be excluded from contact sports permanently”; “The utility of pre-season medical screening is derived from the history; as such, student-athletes should complete a questionnaire, with physical examination reserved for only those with a positive relevant history”; “Femoroacetabular impingement is a myth—the designation of anatomic variation as disease”; “An AC (acromioclavicular) separation in a contact athlete should not be treated surgically if the athlete won't give up the sport; it will fail”; “Ankle taping induces weakness and atrophy of the dynamic stabilizers of the ankle”; “Only autografts should be used in ACL (anterior cruciate ligament) surgery, as allografts have an unnecessary high failure rate in clinical practice.” One statement was accepted as true: “Surgery to treat anterior (patello-femoral) knee pain in a patient with normal patellar mechanics and stability is contraindicated.” In short, expert opinion may be a helpful adjunct to clinical practice. Expert opinion cannot replace individual judgment and certainly does not trump the primary medical literature. Yet when better evidence is lacking, expert opinion is valuable for even the staunchest practitioner of evidence-based medicine.

Sujeitos com Síndrome da Dor Patelofemoral apresentam fraqueza muscular e menores cargas plantares - Relato de Caso

Introdução: A Síndrome da Dor Patelofemoral (SDPF) caracteriza-se como dor difusa na região anterior do joelho. Objetivo: Avaliar a distribuição da pressão plantar durante duas atividades funcionais, subir e descer escadas, bem como torque e trabalho dos flexores e extensores do joelho em um sujeito com e um sem SDPF. Método: Realizou-se avaliação da distribuição da pressão plantar durante duas atividades funcionais, subir e descer escadas, e avaliação isocinética dos flexores e extensores do joelho, além verificar a intensidade da dor antes e após cada atividade em um indivíduo com e um sem SDPF. Resultados: O sujeito com SDPF apresentou menor tempo de contato e menores valores para a integral pressão-tempo, bem como menor pico de torque e trabalho dos flexores e extensores do joelho. Conclusão: A SDPF levou a redução da carga no membro comprometido ao subir e descer escadas e a fraqueza dos flexores e extensores do joelho.

Infrapatellar fat pad may be with tendon repairing ability and closely related with the developing process of patella Baja

Patella Baja, as a common complication of knee trauma or knee surgery, was very difficult to deal with, and scarring and shortening of the patellar tendon were looked on as the most important reason for it. Infrapatellar fat pad, also known as Hoffa’s fat pad was traditionally regarded as with only buffering and lubricating functions in knee joints, which can limit the knee’s excessive activities, absorb shocks from the anterior knee and reduces friction between the patellar tendon and the tibia, it should be with direct protection function and avoid the damage of patella tendon. Recently, a large number of studies had shown that adipose tissue was an accessible and abundant source of mesenchymal stem cells for tissue engineering. Adipose derived stem cells (ADSCs) can be induced to differentiate into adipocytes, osteoblasts, nerve cells, tendon cells and so on. In addition, interestingly, infrapatellar fat pad were just located behind the patellar tendon, and SDF-1 (stromal cell-derived factor-1), as a powerful cytokine that regulates inflammatory cell recruitment and stem cell homing, was unregulated after ligament injury, so there may be a certain correlation between ADSCs from infrapatellar fat pad and injured tendons, maybe ADSCs from infrapatellar fat pad can biologically repair injured tendons when patella tendon was damaged. We hypothesized injured patella tendon repairing should include not only the self-repairing of the tendon, but also the biological repairing from ADSCs in infrapatellar fat pad. When both of the repairing failed to repair the damage of the tendon, patellar tendon may begin to shrink and scar, which will result in patella Baja. In our opinion, healthy infrapatellar fat pad was with direct protection function of patella tendon and full of rich ADSCs, which may play an important part in patella tendon repairing and the developing process of patella Baja.

Anterior Cruciate Ligament Reconstruction Using the Medial Third of the Patellar Tendon

To evaluate the mid-term outcome of anterior cruciate ligament (ACL) reconstruction using the medial third of the patellar tendon as the bone-patellar tendon-bone (BPTB) graft. 79 men (34 right knees and 45 left knees) aged 20 to 52 (mean, 28) years underwent ACL reconstruction using the medial third of the patellar tendon with bone plugs and were followed up for a minimum of 3 years. Stability was assessed using the Lachman test and the pivot shift test. The range of motion, donor-site symptoms, Lysholm knee score, and International Knee Documentation Committee (IKDC) score were also recorded. In terms of stability, only 4 patients had a grade-2 laxity postoperatively, compared to all having a grade-2 or -3 laxity preoperatively. Regarding the range of motion, extension loss was <3º in 76 patients and 3º to 5º in 3, whereas flexion loss was <5º in 73 patients, 5º to 15º in 5, and 16º to 25º in one. No patient had patellar tendon rupture/shortening, patellar fracture, or patellar maltracking. The mean Lysholm knee score improved from 48 to 92 (p<0.0001); scores were excellent (>90) in 46 patients and good (83-90) in 32 patients. The overall IKDC score was grade A (normal) in 9 patients, grade B (near normal) in 66, and grade C (abnormal) in 4. Three of the latter patients had osteoarthritic changes and pain on minimal physical activity. Only one patient had a sensation of partial giving way during moderate physical activity. 20% of the patients had anterior knee pain. Outcome of ACL reconstruction using the medial third of the patellar tendon was comparable to that using the central third of the patellar tendon. In addition, there were no instances of patellar tendon rupture/shortening, patellar fracture, or patellar maltracking.

Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study

Objective: To examine the effects of foot orthosis intervention during a 60-minute running test in pronated-foot runners with overuse knee or foot pain during running. Design: A randomized, controlled design. Setting: Sports gym. Participants: Twenty-four runners with pronated foot who experienced pain over anterior knee or foot region during running were recruited and randomized into the treatment, or the control, group. Interventions: A soft insole with a semi-rigid rearfoot medial wedge was given to the treatment group, and a soft insole without corrective posting was applied to the control group. Outcome measures: The immediate and short-term effects of orthosis application on incidence of pain, pain intensity and onset time were evaluated using the 60-minutes treadmill test. Results: Immediately after wearing the foot orthosis, pain incidence reduced in the treatment group but not in the control group (P = 0.04). After two weeks, seven (58%) subjects in the treatment group and one (8%) in the control group were free of pain during the test (P = 0.01). The pain intensity score decreased significantly after orthosis application, from 35.5 to 17.2 (immediate effect, P = 0.014), then to 12.3 (short-term effect, P < 0.001). Conclusion: The rearfoot medially-wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot.

Foot orthoses for patellofemoral pain in adults

Foot orthoses, which are specially moulded devices fitted into footwear, are one of the treatment options for patellofemoral or anterior knee pain. To assess the effects of foot orthoses for managing patellofemoral pain in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register (March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 11), CINAHL (1937 to March 2010), trial registers, reference lists and grey literature. No language restriction was applied. We included randomised or quasi-randomised clinical studies that compared foot orthoses with flat insoles or another physical therapy intervention. The primary outcomes were knee pain and knee function. Two authors independently selected eligible trials, assessed methodological quality and performed data extraction. We calculated risk ratios and 95% confidence intervals for dichotomous variables, and mean differences with 95% confidence intervals for continuous variables. We pooled data using the fixed-effect model. Two trials with a total of 210 participants were included. Both trials were at some risk of performance bias. One trial had four intervention groups and the other had three. One trial found that foot orthoses when compared with flat insoles (control group) had better results at six weeks in knee pain (participants with global improvement: risk ratio 1.48, 95% confidence interval 1.11 to 1.99), but not at one year follow-up. Participants in the orthoses group reported significantly more minor adverse effects (e.g. rubbing, blistering) compared with the flat insole group (risk ratio 1.87, 95% confidence intervaI 1.21 to 2.91). Both trials in their comparisons of orthoses plus physiotherapy versus physiotherapy alone found no statistically significant differences between the two intervention groups in knee pain or function. Results for knee pain outcomes did not show significant differences between foot orthoses versus physiotherapy. Although participants in the physiotherapy group had consistently better results for the functional index questionnaire, the clinical relevance of these results is uncertain. While not robust, the available evidence does not reveal any clear advantage of foot orthoses over simple insoles or physiotherapy for patellofemoral pain. While foot orthoses may help relieve knee pain over the short term, the benefit may be marginal. Patients treated with orthoses are more likely to complain of mild adverse effects and discomfort.

Osgood-Schlatter Disease: Practical Treatment for a Self-Limiting Condition

Osgood-Schlatter disease is one of the most common causes of knee pain in active adolescents. It is a generally benign disturbance at the junction of the patellar tendon and the tibial tubercle apophysis, and treatment during its 12- to 24-month course should be matched to severity. Mild symptoms require only patient education and moderation of activity, but severe symptoms call for a period of rest (or, rarely, immobilization) followed by aggressive quadriceps strengthening. Other conditions such as Sinding-Larsen-Johansson disease may occur simultaneously, and long-term effects can include a prominence on the anterior knee or painful kneeling.

Techniques of proprioceptive evaluation of the anterior cruciate knee ligament

The increasing interest in sports activities, combined with the knee’s anatomical vulnerability and complexity, justifies the increasing number of patients with ligament injuries, especially the anterior cruciate ligament (ACL). What then would be the best way to evaluate the knee proprioception? The objective of this study was to identify the techniques of proprioceptive evaluation of the anterior cruciate knee ligament (ACL), and to determine whether a better technique is available. The method was to review the literature, including only those studies published in indexed scientific journals that referred to evaluation tools and/or knee proprioception measurement. The discussion of the different methods of evaluating ACL proprioception, according to the literature, included: morphological anatomical studies; neurophysiologic evaluation, and clinical evaluation which was divided into three types: a) sense of static position; b) kinesthetic posture; and c) postural balance. Although proprioception is important to the final results of a treatment involving ligament injury, its evaluation is still a problem. The conclusion was that the ideal method should have high sensitivity and specificity, in addition to good reproducibility and accuracy. There is lack of consensus in literature regarding the best evaluation technique and the results are also contradictory, despite the balance evaluation being a modern technique used in major research centers, it was not possible to isolate the proprioceptive system from other systems: visual and vestibular.

Mycobacterium fortuitum Infection Following Patellar Tendon Repair

Mycobacterium fortuitum is a ubiquitous, rapidly growing mycobacterial species that is infrequently reported in the surgical literature. Clinically important infection with this organism has been described following trauma, injections, augmentation mammoplasty, and ultrasound hydrolipoclasia1-3. In the field of orthopaedic surgery, Mycobacterium fortuitum infection has been encountered only following prosthetic arthroplasty or fracture surgery with internal fixation4-9. We report the case of an otherwise healthy man who underwent patellar tendon repair that was complicated by Mycobacterium fortuitum infection. While an accurate diagnosis was delayed by several weeks, aggressive surgical and specific antimicrobial therapy resulted in a favorable outcome. We emphasize the importance of surgeon awareness of this pathogen in order to facilitate accurate diagnosis and appropriate treatment. The patient was informed that data concerning the case would be submitted for publication, and he consented. A forty-year-old man who worked as an attorney was referred to one of us from another institution two months after surgical repair of the left patellar tendon. Three weeks before the referral, the patient had surgical wound erythema and drainage, accompanied by fever and chills. Oral cephalexin was prescribed but resulted in no improvement. Culture specimens were not obtained at that time. The medical history was otherwise unremarkable. Examination revealed that the patient was 180 cm tall and weighed 95 kg. The systemic temperature, pulse rate, and blood pressure were normal. The patient had an anterior longitudinal left knee incision with diffuse, severe surrounding erythema. The wound was open and draining, with granulation tissue exposed both proximally and in the center. The range of knee motion was from 0° to 70°. The patellar height appeared to be symmetrical on both sides, and the patient could perform an active straight leg raise. Distal motor and sensory function was …

A Wide Spreading Method in Commits Suicide

In the recent 5 years, there is an emerging local trend of burning charcoal as a form of suicide attempt. Patients who committed suicide usually suffered from carbon monoxide inhalation lung injury and severe deep contact thermal burns if direct fall down on the burning charcoal. Patients are usually admitted to the burn unit and received burn wound management. Early wound closure and better functional results are the goals. We reported a female patient who committing suicide by burning charcoal. Her anterior and lateral knee joint suffered from the 5% body surface third degree burn injury. Very early tangential excision was performed and free anterolateral thigh cutaneous flap (28x21 cm) was transferred immediately after wound debridement to cover the joint capsule and quadriceps tendon. The patient recovered both emotionally and physically and was discharged 18 days after the admission.

Knee Pain in a Gymnast

HISTORY: A 13 yo level 10 gymnast developed gradual onset of right knee pain which interfered with competition. She presented to an outside physician and was diagnosed with "improper patellar tracking". She took 4 weeks off from gymnastics and underwent formal PT for LE/core strengthening. She then had 2 months of significant improvement and was able to successfully compete in Nationals. Her symptoms returned shortly thereafter. She presented to us with constant aching pain in her anterior knee and intermittent swelling 6 months out from her. She noted worsening of symptoms with ambulation and stairs. She denied any episodes of locking, clicking or give-way weakness. She had no relief of symptoms on scheduled Ibuprofen. PHYSICAL EXAMINATION: Inspection reveals 1+ effusion. No tenderness on palpation of the tibial tubercle. ROM is to full extension and 130 degrees of flexion. Pain with patellofemoral compression and with deep knee flexion. No crepitus. Negative Lachman and Posterior Drawer. No instability with valgus or varus stress. Hip abductors 3+/5 bilaterally. Hamstring popliteal angle of 45 degrees. Normal neurovascular exam. DIFFERENTIAL DIAGNOSIS: Patellofemoral Pain Syndrome Medial Plica Syndrome Osteochondritis Dissecans Tibial Apophysitis TEST AND RESULTS: MRI Right Knee performed at outside hospital: - Subchondral bone defect on the medial femoral trochlea. Overlying cartilage intact. Radiologist made mention of possible eosinophilic granuloma vs. chondroblastoma and recommended CT scan. CT Right Knee: - Subchondral defects of medial femoral trochlea. FINAL WORKING DIAGNOSIS: Osteochondritis Dissecans of medial femoral trochlea. TREATMENT AND OUTCOMES: MRI at time of eval in our clinic 6 months out from initial MRI/CT scan revealed decreased bone edema to medial femoral trochlea. WBAT in Knee Immobilizer for 12 weeks. F/U MRI at 9 months with continued healing and resolution of cysts. Transition out of Knee Immobilizer, but no weighted squats. F/U MRI at 11 months with only subtle residual hyperintensity and no osteochondral lesion. Progress to gradual return to gymnastics under PT guidance.

Decreased eccentric muscle endurance in the conservatively treated anterior cruciate-deficient knee

Concentric (CON) and eccentric (ECC) isokinetic knee extensor endurance, during 100 repetitive isokinetic contractions, were analysed in 32 consecutive patients with conservatively treated unilateral anterior cruciate ligament ruptured knees. There were 20 men and 12 women (mean age 34 years). The test was performed 6.8 years after the injury (range 4–14). The uninjured leg in each patient served as control. Lysholm subjective score, Tegner activity score and IKDC grading were used to relate the subjective knee function to muscle performance. Knee extensor endurance for concentric as well as for eccentric contractions were significantly lower in the injured side than the uninjured side. The magnitude of decrease in muscle performance was 7.6% for concentric (range-12 to 27%) and 15.3% for eccentric (range -9 to 50%) endurance. The eccentric injured/uninjured endurance ratio correlated significantly to the Lysholm subjective score. We conclude that the knee extensor endurance is decreased in patients with conservatively treated anterior cruciate ligament-ruptured knees. The eccentric endurance test seems to reflect the patients' subjective knee functioning.

Auswirkungen der Entnahme des mittleren Patellarsehnendrittels auf die Kinematik des Kniegelenkes und den retropatellaren Druck

This biomechanical study was performed to evaluate the consequences of removing the central part of the patellar tendon on the kinematics and kinetics of the femoro-patellar joint. The tendonectomy was performed in the same manner as is frequently done during anterior cruciate ligament reconstructions. Of particular interest in this study was to identify potential factors of the patellar tendon resection which could result in anterior knee pain. A simulated isokinetic knee extension from 120 degrees of flexion to full extension was performed on nine human knee cadaver specimens. Joint kinematics was evaluated with ultrasound sensors, and retropatellar contact pressure was measured using a thin-film resistive ink pressure measuring system. Data were taken before and after resection of the central third of the patellar tendon. Harvesting of the central third of the patellar tendon resulted in an elongation of the remaining patellar tendon by less then 0.5 mm. Furthermore, increases in patellar flexion lower than 1 degree were observed. Small changes in retropatellar pressure were also observed. The shortening of the patellar tendon due to tendon removal, as already suggested in several previous studies, is not attributed to the removal of the central portion of the tendon itself, but more likely due to secondary scarring contraction of the tissue. The changes of the patellarkinematics and the retropatellar pressure observed in this study are probably not of any clinical significance.

SAPHO Syndrome with a Tumour-like Bony Proliferative Lesion in Distal Femur. ACase Report

SAPHO syndrome is a group of bone and joint abnormalities associated with skin lesions. A 29-year-old male presented with severe acne on his trunk and anterior chest wall, right knee and foot pain. Radiographs and magnetic resonance images showed hyperostosis in the sternocostoclavicular region, sclerosis of one-third of the right distal 5th metatarsal bone and bony outgrowth from the medial condyle of the right femur. The histological findings of the biopsy specimen were consistent with those of old osteomyelitis. All fungal and microbacterial cultures were negative. Pain and swelling of the right knee and foot repeated remission and aggravation. There were no radiological changes of the above-mentioned lesions noted within 4-years follow-up.

Elongamento do enxerto de tendões do músculo grácial e semitendinoso humanos: estudo realizado em cadáveres de adultos jovens

Na cirurgia de reconstrução do ligamento cruzado anterior do joelho, os enxertos de tendões autólogos são a principal opção como substitutos ligamentares. Entretanto, uma das razões da falha da reconstrução ligamentar com tecidos moles é o estiramento ou elongamento do enxerto com o tempo. Neste trabalho, foram ensaiados oito tendões do músculo grácil e oito do músculo semitendinoso humanos, obtidos de quatro cadáveres do sexo masculino, com idade média de 24,5 anos. Cada tendão foi submetido a uma deformação relativa constante de 2,5% durante 600 s, com registro contínuo do relaxamento de força. A seguir, o tendão retornava ao seu comprimento inicial e era mantido num período de repouso de 300 s. Após este intervalo, um segundo ensaio, semelhante ao primeiro, era realizado. A velocidade de carregamento empregada foi de 10% do comprimento inicial do corpo de prova por segundo. Foram obtidos valores de força inicial, com 300 s e 600 s nos dois ensaios. A análise estatística sugere um comportamento mecânico mais uniforme para o tendão do músculo semitendinoso quando comparado ao tendão do músculo grácil.

Unreamed Interlocking Nailing in Open Fractures of Tibia

To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.

Is radiologic examination necessary for a 9-year-old girl with a knee injury?

The purpose of “Evidence in Practice” is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated. The father of a 9-year-old girl contacted our clinic to schedule an examination. He reported that his daughter injured her left knee during gymnastics practice the previous evening. He stated that, while attempting to perform a forward flip maneuver, she heard a “pop” in her left knee as she initiated the jump. According to witnesses, the girl landed awkwardly on her heels, with her knees bent, and she subsequently fell backward into a sitting position. The girl reported immediate anterior left knee pain following the maneuver. Because of her pain, she had been unable to walk since the time of the injury. Her father spoke to a physical therapist (Smith) at our clinic to relay this information and to express urgency in the case. The patient had not seen another medical professional for the injury. The father was a former client at our clinic and, therefore, sought our opinion about his daughter's injury. The girl had not yet undergone an examination or diagnostic imaging; therefore, we would be serving as a point of entry to the health care system. We planned to assess the extent of the injury in order to determine whether referral to another medical specialist was warranted. The patient's history of trauma during a high-velocity maneuver (ie, forward flip) and her inability to walk the following day indicated the possibility of a fracture, a growth plate injury, or some other serious injury (eg, ligamentous or meniscal injury). The prevalence of ligamentous or meniscal injury in knee trauma is much larger than the prevalence of fractures; less than 7% of …

Non-opioid analgesics: other: The use of intraarticular clonidine for the management of complex regional pain syndrome of the knee

CRPS of the knee is poorly understood and difficult to treat. We have previously reported the efficacy of IVRA with clonidine for CRPS of the knee (J Clin Anesth 2002). Intraarticular (IA) clonidine has proven to be an effective analgesic when administered for arthroscopic knee surgery (Anesth Analg 1999) and may contribute to a decreased incidence of CRPS following ACL surgery (Reg Anesth Pain Med 2002). We report the efficacy of IA clonidine in the management of CRPS of the knee. A 22-year old 60 kg female complained of burning pain (VAS=9) over the anterior aspect of the knee, joint stiffness and diffuse hyperesthesia after blunt trauma to the knee. Examination revealed tenderness over the patellofemoral joint, mottling of the skin over the anterior knee, decreased ROM, and decreased temperature (1.3° C) compared to the contralateral extremity. Physical therapy, NSAIDs, and TCAs provided no improvement. An IA injection of 30 mL 0.25% bupivacaine and 60 μg clonidine was performed each week for 6 consecutive weeks. The first IA injection resulted in complete pain relief for 2 days after which the pain gradually returned to a lower intensity (VAS=6). She also noticed a reduction in the stiffness and color changes of the affected extremity. A second IA injection provided 6 days of pain relief after which the pain returned to a lower intensity (VAS=3). Three more successive IA blocks with clonidine were performed on consecutive weeks resulting in complete resolution of her CRPS symptoms. The patient has remained pain-free for 6 months after the last treatment. IA clonidine may be beneficial in the treatment of CRPS of the knee.

Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients. A Preliminary Report

To The Editor: We read the article, “Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients. A Preliminary Report” (2003;85:1255-63), by A.F. Anderson. Clearly, the author is attempting to address a difficult problem in relation to the anterior cruciate-deficient knee in early adolescence. The mean age in his series was 13.3 ± 1.4 years, which is three to four years prior to epiphyseal closure in the femur and tibia in boys. By the same token, the epiphysis also has the potential for growth during this period, and therefore, with time, the consequences for the graft will be either stretching or, if stretching is not encountered, gradual tunnel enlargement, particularly on the femoral side. Also, the need to avoid violation of the physis will make tunnel placement that avoids impingement on the tibial side and anatomic siting on the femoral side extremely difficult to perform and certainly, on the femoral side, it is unlikely that the tunnel siting will be reproducible. We noted with particular interest that the guide wire placement illustrated by a lateral view of the tibia (Fig. 2) in the article is only 25% of the anteroposterior diameter of the tibial plateau and therefore would be highly likely to produce an anterior tunnel placement, which would subsequently produce graft impingement. The opinion that isometric ligament placement either can be achieved or indeed is desirable is open to question, and, given that the over-the-top route has … Corresponding author: Christos K. Yiannakopoulos, MD Byzantiou 2 171 21 Nea Smyrni Athens Greece cky{at}ath.forthnet.gr