Habitual Dislocation Research Articles

Surgical Options for Patellar Stabilization in the Skeletally Immature Patient

Patellar dislocations in children and youth are estimated to occur in 29 of 100,000 individuals. Recurrent patellar dislocations in the skeletally immature patient are often associated with distinct pathoanatomies, which include patella alta, trochlear dysplasia, and contractures of the central and/or lateral structures of the extensor mechanism. This paper discusses the features of patellar instabilities classified as traumatic versus atraumatic, congenital versus acquired, and fixed dislocations versus habitual dislocations. Suggestions for the surgical management of these various classifications of patellar instabilities, on the basis of the principle of identification and correction of the pathoanatomies unique to the individual, are provided.

A Trilogy Constrained Acetabular Component to Treat a Late Recurrent Dislocation after a Total Hip Arthroplasty

Dislocation is one of the major complications resulting from total hip arthroplasty. It is both physically destructive and mentally discouraging. A constrained liner is one of the treatment options for addressing dislocation in some selected patients. A 78-year-old woman presented with late habitual hip dislocation. Her medical history revealed that she had undergone a left total hip replacement 10 years earlier. Physical examination revealed pain in the right thigh and a limping gait caused by the loosening of the femoral stem following right total hip replacement. She underwent left revision acetabular cup surgery and the previously installed cup was replaced with a new Trilogy constrained liner. No further dislocations had occurred at 36-month follow-up. She recovered completely and is now able to engage in daily physical activities.

The "Four-in-One" Procedure for Habitual Patellar Dislocation in Children with Formation Failure of Femoral Trochlea and Generalized Ligamentous Laxity - A Preliminary Report -

Purpose : To evaluate the clinical results of a Four-in-One procedure for a habitual dislocation of the patella in children with generalized ligamentous laxity and formation failure of the femoral trochlea. Materials and Methods : Five knees in 4 patients were included in this study. The average age of the patients at the time of surgery was 5.9 years and the subjects were followed up for an average of 41.6 months postoperatively. The clinical results were evaluated using the criteria of the Kujala's scoring system as well as a physical examination and radiological findings. Results : During the follow-up period, there were no recurrent dislocations, knee joint pain, limitations of motion or gait disturbances in any of the cases. The mean Kujala score was 96.8. Two cases had complications related to wound healing but they healed eventually. Conclusion : The Four-in-One procedure, which include the lateral retinacular release, medial vector augmentation, semitendinosus tenodesis, and patellar tendon transfer is recommended for a habitual dislocation of the patella in children with generalized ligament laxity and formation failure of the femoral trochlea.

Specific expression of substance P in synovial tissues of patients with symptomatic, non-reducing internal derangement of the temporomandibular joint: Comparison with clinical findings

Our aim was to find out the extent of expression of substance P in synovial tissue from the human temporomandibular joints (TMJ) with symptomatic, non-reducing internal derangement, and to investigate the relationship between substance P and clinical findings. Fifty-four joints in 54 patients were examined immunohistochemically. Specimens of synovial tissue from 10 joints in 8 subjects with habitual dislocation of the TMJ with no pain were examined as controls. Cells that stained for substance P were found mainly among the endothelial cells in the blood vessels beneath the lining cells in synovial tissues from 47 of the 54 joints (87%) with internal derangement and from 5 of the 10 control joints. The extent score of cells that stained for substance P in joints with internal derangement was significantly higher than that in controls ( p = 0.02). The extent score of these cells did not correlate with pain in the joint or the degree of synovitis. These results suggest that substance P may have some roles in both the physiological and pathological conditions in patients with symptomatic internal derangement of the TMJ.

Expression of interleukin 8 in synovial tissues in patients with internal derangement of the temporomandibular joint and its relationship with clinical variables

The objectives of this study were to assay interleukin 8 (IL-8) in synovial tissues of the temporomandibular joint (TMJ) with symptomatic internal derangement, and to assess its relationship with clinical variables. Forty-six joints in 44 patients were examined using an immunohistochemical technique. As controls, 8 joints in 7 subjects with habitual dislocation without pain were also examined. IL-8 was expressed mainly in the blood vessels beneath the lining cells in 37 of the 46 joints (80%) with internal derangement and in 2 of the 8 control joints. The percentage of IL-8-positive cells was significantly higher in the internal derangement group than in the control group (P = .004). The percentage of IL-8-positive cells showed no correlation with joint pain or number of infiltrating cells. IL-8 was up-regulated in inflamed synovial tissues in patients with internal derangement. Because IL-8 has no significant correlation with clinical variables, IL-8 may play a secondary role in the pathogenesis of the internal derangement of the TMJ.

O.251 Eminectomy for habitual dislocation under local Anaesthesia: an experience with 11 cases

A 71-year-old man was referred to the Department of Oral and Maxillofacial Surgery at Westmead Hospital for investigation of limited jaw movement and facial pain after a cerebrovascular event eight weeks previously. He was found to have bilateral dislocations of the temporomandibular joints (TMJ) and was successfully treated with a combination of intermaxillary fixation (IMF) screws and botulinum toxin A.

Expression of capsaicin receptor TRPV-1 in synovial tissues of patients with symptomatic internal derangement of the temporomandibular joint and joint pain

To elucidate expression of capsaicin receptor TRPV-1 in synovial tissues of the human temporomandibular joint (TMJ) with internal derangement and discuss its relationship with joint pain. Fifty-four TMJs in 54 patients were examined using an immunohistochemical technique. As controls, 10 TMJs with habitual dislocation without pain were also examined. TRPV-1 was expressed mainly in the blood vessels beneath the lining cells in synovial tissues from 31 of the 54 joints with internal derangement and from 8 of the 10 control joints. The extent score of TRPV-1-stained cells with internal derangement was not significantly higher than that of controls. The extent score of TRPV-1 showed no correlation with joint pain. TRPV-1 was detected in the region of the posterior disk attachment of synovial tissues from the TMJ in patients with internal derangement and controls. TRPV-1 may play a role in maintenance of the physiologic condition of the TMJ.

A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation

The management of patellar dislocation syndrome has traditionally been difficult. There are no golden standard methods for patellar dislocations probably due to the many etiologies. However, it is known that medial patellofemoral ligament (MPFL) is damaged when the patella is dislocated. The purpose of this study is to examine whether our method of MPFL reconstruction is useful for the treatment of dislocated patellae and unstable patellae. Forty-six knees (43 patients) of 68 knees (65 patients) that were operated on using our surgical procedure for MPFL reconstruction with the advancement of the vastus medialis or the MPFL reconstruction with Insall's procedure were followed up for at least 5 years. The patient age ranged from 6 to 43 years. These knees consisted of six habitual dislocation patellae, twenty-six recurrent dislocation patellae, ten traumatic dislocation patellae, and four unstable patellae. The patients were evaluated pre-operatively and more than three times post-operatively at 6, 12, 36, 60, or 120 months. No patient experienced patellar dislocation after surgery. Their post-operative Kujala's scores were significantly improved. On conventional X-ray and on stress X-ray evaluations, the mean values for congruence angle, tilting angle, lateral shift ratio, medial stress shift ratio, and lateral stress shift ratio at the final follow-up (60 or 120 months) were demonstrated to be within the normal range. We conclude that our MPFL reconstruction method with the advancement of the vastus medialis or with Insall's procedure might be recommended for the treatment of habitual, recurrent, and indeed any other type of patellar dislocation, as well as for unstable patellae.

Multidirectional Habitual Bilateral Hip Dislocation in a Patient with Down Syndrome

A multidirectional (anterior and posterior) bilateral habitual nontraumatic dislocation of the hip in a 3-year-old girl with Down syndrome is reported. The treatment was conservative with application of a spica cast for 12 weeks to shrink the capsule. During the first 6 weeks of treatment, the hips were immobilized in abduction and full external rotation. During the last 6 weeks, the hips were in abduction and slight internal rotation. After cast removal, the hips seemed to have been stabilized, and the child has remained asymptomatic for the last 12 months.

Relationship of calcitonin gene-related peptide in synovial tissues and temporomandibular joint pain in humans

Objective To elucidate the expression of calcitonin gene-related peptide (CGRP) in synovial tissue taken from the human temporomandibular joint (TMJ) with internal derangement, and discuss the relationship between CGRP and joint pain. Study design Using an immunohistochemical technique, 48 joints in 48 patients were examined. As controls, synovial tissue specimens from 7 joints with habitual dislocation without pain were also examined. Results In all of the internal derangement and control subjects, CGRP-positive cells were observed in the connective tissues around the blood vessels beneath the lining cells. The extent score of CGRP was significantly higher in the internal derangement group than in the control group ( P = .033). There was a significant positive correlation between the extent score of CGRP and joint pain ( P = .036, r = 0.30). Conclusions These results suggest that the expression of CGRP is increased in the synovial tissues from patients with internal derangement, and that CGRP seems to play an important role in the mechanism of pain production in patients with symptomatic internal derangement.

Levels of fibroblast growth factor 2 in synovial fluids in human patients with internal derangement of the temporomandibular joint.

We sought to elucidate the levels of fibroblast growth factor 2 (FGF-2) in synovial fluid taken from internally deranged human temporomandibular joints (TMJs) and to discuss the role of FGF-2 in the pathogenesis of internal derangement. Through the use of a pumping procedure, diluted synovial fluid was collected from the upper joint compartment of 22 TMJs with evidence of internal derangement (21 patients) and 8 TMJs with no such evidence (5 control subjects). Two of the control subjects were patients who had habitual dislocation, and three were healthy volunteers. The level of FGF-2 in the synovial fluid was assessed by means of an enzyme-linked immunosorbent assay. FGF-2 levels were at detectable levels in 15 of the 22 TMJs (68%) with internal derangement. The mean concentration of FGF-2 was 24 pg/mL. In the control group, FGF-2 levels were detectable in only 1 of 8 joints (13%), for a concentration of 3 pg/mL. The mean concentration of FGF-2 in the synovial fluid was significantly higher in the internal derangement group than in the control group (P =.02). FGF-2 levels are elevated in the human synovial fluid of TMJs with internal derangement.

Cementless Mallory-Head HA-coated hip arthroplasty for osteoarthritis in hip dysplasia

Sixty-three cementless Mallory-Head HA-coated femoral prostheses (Biomet, Warsaw, IN) were used in primary total hip arthroplasty in 50 patients with osteoarthritic hips because of congenital hip dysplasia. The implanted cup was also cementless (41 Harris Galante and 22 Ringlock). The patients were followed up for a mean period of 75.1 months (range, 44–110). Clinical and radiologic analysis were performed. Harris Hip Score increased from 42 to 90 points; 97% of the patients had no or only mild pain, and limping decreased from 90% to 20%. Complications were marginal: no infections, one habitual dislocation, one peroperative fracture of the femur, and one transient ischiadic nerve palsy. Two HG cups were revised for augmented polyethylene wear. Radiographically, no subsidence of the prosthesis or bone atrophy of the proximal femur could be detected. No correlations were found between the radiologic phenomena and the clinical outcome, but the tightness of the prosthesis fit had a definitive influence on the radiographic bone remodeling pattern. The cementless Mallory-Head HA-coated femoral prosthesis shows excellent clinical and radiological mid-term results in osteoarthritic hip dysplasia patients. There was no need for the use of a specially designed dysplasia femoral prosthesis.

Habitual dislocation of the hip in children: report of eight additional cases and literature review.

The purpose of this study was to report eight additional cases of habitual dislocation of the hip (HDH) and to combine the authors' data with a compilation of the cases from the literature. The authors attempted to investigate the various causative factors, outcomes, and indications for conservative and operative treatments. The results suggest that an unusual ability to dislocate the hip voluntarily at a young age constitutes a specific pediatric entity, and no single factor can be determined to be the definite cause of HDH. Multiple triggering factors (generalized ligamentous laxity, excessive anteversion of the femur and acetabulum, osteocartilaginous defect of acetabulum, coxa valga, psychiatric immaturity) appear to be associated with HDH. Treatment should be conservative in the first instance; it includes simple observation with or without psychiatric counseling and immobilization with cast or brace. Hip stabilization by surgical means is selectively indicated when the episodes of hip dislocation do not fade away in due time despite conservative treatment and when primary or secondary capsular laxity or osteocartilaginous deformation or defect of the hip is severe enough to cause repeated dislocation or residual subluxation, which may cause persistent pain or discomfort.

Habitual Dislocation of the Hip in Children: Report of Eight Additional Cases and Literature Review

Habitual Dislocation of the Hip in Children: Report of Eight Additional Cases and Literature Review

Expression of interleukin 6 in synovial tissues in patients with internal derangement of the temporomandibular joint

Using an immunohistochemical technique, we examined synovial tissue from 46 temporomandibular joints (TMJ) with internal derangement in 44 patients. As controls, we examined synovial tissue specimens from 7 joints with habitual dislocation without pain. In synovial tissues from 21 of the 46 joints with internal derangement, interleukin 6 (IL-6) was expressed in the synovial lining cells and in the mononuclear cells infiltrating the periphery of the blood vessels. The density of IL-6-stained cells in specimens with internal derangement correlated significantly with the grade of joint effusion shown by magnetic resonance imaging ( P=0.01, r=0.32).

Radiographic classification of glenohumeral arthrosis

We studied the interobserver agreement of two radiographic classification systems for evaluation of glenohumeral arthrosis in 40 patients at long-term follow-up after the Eden Hybbinette operation for habitual dislocation of the anterior shoulder. Both observers agreed that none of the patients had severe arthrosis. The Samilson-Prieto system showed agreement using the classification in 35 of 40 operated shoulders (kappa 0.76). The Kellgren-Lawrence system showed agreement using the classification in 23 of 40 operated shoulders (kappa 0.36). The rate of arthrosis in the operated shoulder ranged from 0.2 to 0.6, depending on the classification system and the observer. None of the patients without arthrosis, but one fifth of those with arthrosis reported pain. The Samilson-Prieto classification is preferable because it is simple to use and has excellent interobserver agreement.

Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella.

We examined 39 patients (45 knees) who had undergone an Elmslie-Trillat procedure for recurrent or habitual dislocation of the patella with a follow-up of more than ten years. The mean age at the time of surgery was 18.4 years; the mean follow-up was 161 months (120 to 238). Using Fulkerson's functional knee score, 41 knees (91%) had an excellent or good result at a mean follow-up of 45 months, and this was maintained in 29 (64%) at the final review. The main cause of deterioration in the clinical results was the onset or worsening of patellofemoral joint pain, not patellar instability.

Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella

We examined an39 patients (45 knees) who had undergone Elmslie-Trillat procedure for recurrent or habitual dislocation of the patella with a follow-up of more than ten years. The mean age at the time of surgery was 18.4 years; the mean follow-up was 161 months (120 to 238). Using Fulkerson’s functional knee score, 41 knees (91%) had an excellent or good result at a mean follow-up of 45 months, and this was maintained in 29 (64%) at the final review. The main cause of deterioration in the clinical results was the onset or worsening of patellofemoral joint pain, not patellar instability.

The expression of vascular endothelial growth factor in synovial tissues in patients with internal derangement of the temporomandibular joint.

The aim of this study was to elucidate the expression and localization of vascular endothelial growth factor (VEGF) in synovial tissue taken from the temporomandibular joint (TMJ) with internal derangement (ID) and discuss the role of VEGF in the pathogenesis of ID. Through the use of an immunohistochemical technique, 39 TMJs in 37 patients were examined. As controls, synovial tissue specimens from 6 joints in 6 patients with habitual dislocation were also examined. In the synovial tissue from 35 of the patients with ID, expression of VEGF was observed in the synovial lining cells, in the endothelial cells of the blood vessels, and in the fibroblasts. In contrast, expression of VEGF was found in the TMJ tissue from only 2 of the controls. The percentage of VEGF-positive cells in the ID specimens was significantly higher than that in the habitual dislocation specimens (P < .02), and the expression of VEGF significantly correlated with the arthroscopic synovitis score (P = .004). These results suggest that the expression of VEGF is upregulated and involved in the development of inflammatory changes in synovial tissues in TMJs with ID.

Femorotibial rotation and the Q-angle related to the dislocating patella

Purpose: To compare the femorotibial rotation, the patellar translation, the hip-knee-ankle angle and the Q-angle in patients with a dislocation of the patella with those of healthy volunteers. Further, the clinically measured Q-angle was compared to that measured by radiography. Material and Methods: A system for measurement of patellar variables was previously developed and applied to 80 healthy volunteers. In the present study, 28 patients (20 women, 8 men) with dislocation of the patella were examined bilaterally. Fourteen patients had habitual dislocations (20 affected knees) and 14 patients traumatic dislocations (17 affected knees). In 20 patients the clinical Q-angle was measured bilaterally by an orthopaedic surgeon and in 9 of these patients also by a second independent orthopaedic surgeon. Results: The most striking finding was that dislocating knees in both groups showed a smaller Q-angle than the healthy knees. Further, the habitual group showed greater relative rotation between the tibia and the femur and an increased patellar translation compared to the traumatic group and to the healthy volunteers. There was a poor correlation between clinical and radiographic measurements of the Q-angle and no correlation was found between two independent clinical measurements. Conclusion: Surgical operations aiming at decreasing the Q-angle should be challenged.