Patellar Insertion Research Articles

Medial patellofemoral ligament injury. Location-based rate of recurrent patellar dislocation after non-operative treatment

ObjectivesThe role of the medial patellofemoral ligament (MPFL) as a patellofemoral joint stabilizing structure is undisputable. After traumatic patellar dislocation, MPFL injury, together with bone edema in the medial patellar facet and lateral femoral condyle, is a pathognomonic finding in magnetic resonance imaging (MRI). MPFL injury in the femoral insertion has been reported to most likely predict recurrent dislocations. The objective of this study was to detect if any MPFL injury location predicts the earliest onset of the patellar re-dislocation. MethodsIn total, 64 eligible patients with a first-time traumatic patellar dislocation were recruited to the trial. The diagnosis was confirmed within 3 weeks with 3T magnetic resonance imaging. The location of the MPFL injury in MRI was localized at the patellar insertion, midsubstance area, femoral insertion, or a combination of these. During the three-year follow-up period, patellar re-dislocations, range of motion, quadriceps muscle atrophy, and daily symptoms were determined. All the patients were treated non-operatively. ResultsOut of 64 patients, 33 (51.6%) had at least one episode of patellar re-dislocation. Re-dislocations occurred in 8 out of 25 (32.0%) patients with the main injury at the femoral insertion, 5 out of 15 (33.3%) patients with the main injury at the midsubstance area, and 10 out of 24 (41.7%) patients with the main injury at the patellar insertion during the 36 months follow-up (p ​= ​0.758). According to Kaplan–Meier analysis, the location of MPFL injury did not have any statistically significant effect on the timing of re-dislocations. At 36 months, survival of patients with MPFL injury at the patellar insertion was 70.8%, which was not statistically significantly different than the survival in patients with injury at the femoral insertion (88.0%) or at the midsubstance area (93.3%). No differences between single and multiple MPFL injuries were found. At 4 weeks, the range of motion was more restricted in patients with MPFL injury at the femoral insertion (93.4° vs. 108.0° for injury at the midsubstance area and 107.7° at the patellar insertion). ConclusionThe location of MPFL injury did not have any statistically significant effect on timing or the rate of re-dislocations. The MPFL injury at the femoral insertion predicts decreased range of motion (ROM) of the knee and increased quadriceps muscle atrophy during the first three months after sustaining injury. Level of evidenceLevel III.

Additional Value of Ultrasound in Patients with Psoriatic Arthritis within Treatment Target.

Background: In psoriatic arthritis (PsA), musculoskeletal ultrasound is a complementary tool to physical examination, useful even in patients in remission to detect subclinical activity. Objectives: The objective of the study was to assess the ultrasound prevalence of active enthesitis and synovitis in patients who reached the therapeutic target. Methods: This cross-sectional study included patients with at least 6 months of therapy with a targeted synthetic or biological disease-modifying antirheumatic drug who were in treatment target (i.e., DAPSA < 14). Patients underwent bilateral clinical and ultrasound examination of the elbow lateral epicondyle, quadriceps insertion, distal patellar tendon insertion, and Achilles enthesis for assessing enthesitis, and hand and foot joints for assessing synovitis. Enthesitis and synovitis were considered active if the power Doppler signal showed at least a score of one. Results: The study included 51 PsA patients, women (52.9%), with an average age of 55 years. Although the patients were within the DAPSA treatment target, 21.6% had at least one painful enthesis at clinical examination, 19.6% had ultrasound evidence of at least one active enthesitis and 15.7% had ultrasound signs of at least one active synovitis. Conclusions: Among PsA patients thought to be within the therapeutic target, ultrasound detected a non-negligible percentage of active enthesitis and synovitis.

Knee rotation in patients with and without patellofemoral instability and its correlation with patellar tendon trochlear groove distance

Background and study aims: There are limited studies assessing the role of “knee rotation” in patellofemoral instability (PFI). Knee rotation is the external rotation of the proximal tibia with respect to distal femur. The study was performed to compare knee rotation, patellar tendon lateralisation and patellar tendon trochlear groove (PTTG) distance measured on MRI between patients with and without PFI and to assess the relative association of these factors with PFI. Materials and methods: It was a retrospective cross-sectional study done on archival MRI films. A sample size of 20 for PFI group and 60 for control group was taken. PTTG distance, knee rotation and lateralisation of patellar tendon insertion were measured as described in literature. The knee rotation and patellar tendon lateralisation between PFI and non-PFI group were compared using t-test and their Pearson’s correlation (r) with PTTG distance was calculated. Relative associations of these factors with PFI were assessed using multivariate regression. Results: Lateralisation of patellar tendon insertion and external knee rotation were both found to be higher in PFI patients as compared to non-PFI patients. However,on taking PTTG distance into consideration, the associations of knee rotation as well as of patellar tendon lateralisation with PFI did not remain significant in generalised linear modeling. Overall, the PTTG distance showed moderate to strong correlation with the external knee rotation as well as with lateralisation of patellar tendon insertion. Conclusions: Knee rotation was found to be significantly higher in PFI patients as compared to controls. However, PTTG distance appears to be a composite measure that takes into account the influence of both the patellar tendon lateralisation as well as knee rotation on patellofemoral biomechanics.

Decreased Effective Patellar Tendon Length following Distalization Tibial Tubercle Osteotomy without Patellar Tendon Tenodesis.

Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Case series; Level of evidence, 4. Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.

Arthroscopic Repair of Acute Traumatic Medial Patellofemoral Ligament Tears at the Patellar Insertion

After a lateral patellar dislocation or subluxation, injury to the medial patellofemoral ligament (MPFL) is common. The MPFL originates between the medial epicondyle and the adductor tubercle, inserting along the superior one-third border of the medial patella. Operative treatment becomes necessary for patients with intra-articular pathology (such as osteochondral injuries or meniscus tears) or those experiencing recurrent dislocations. Numerous surgical techniques have been proposed for addressing this issue, with MPFL reconstruction being the most frequently performed procedure. Nonetheless, various complications associated with reconstruction have been documented. In recent years, there has been a growing interest in MPFL repair, which has shown acceptable outcomes in the literature. In this study, we introduce an arthroscopic-assisted MPFL repair technique designed for acute traumatic MPFL tears originating from the patellar insertion. This approach offers the advantage of being minimally invasive, straightforward, and reproducible.

MPFL Behavior in Traction Tests after Width Equalization of Patellar and Femoral Insertions

MPFL Behavior in Traction Tests after Width Equalization of Patellar and Femoral Insertions

Length Changes of the Medial Patellofemoral Ligament During In Vivo Knee Motion: An Evaluation Using Dynamic Computed Tomography

Background: Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns. Purpose: To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint. Study Design: Descriptive laboratory study. Methods: Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity–trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed. Results: The proximal fiber was the longest in full extension and progressively decreased to a median length of −6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity–trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range. Conclusion: The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior. Clinical Relevance: In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.

Cranial tibial translation measurements for radiographic diagnosis of cranial cruciate ligament rupture in dogs.

To assess the effect of tibial compression on radiographic cranial tibial translation measurements in healthy dogs and those with cranial cruciate ligament (CCL) rupture and establish specific criteria for the radiographic diagnosis of CCL rupture. 60 dogs. Dogs were divided into 3 groups with 20 dogs each: group 1, healthy adult dogs; group 2, adult dogs with CCL rupture; and group 3, healthy young dogs. For each dog, 2 images of the stifle joint in mediolateral projection were taken, of which 1 was conventional and 1 was under tibial compression. Variables were measured in each radiographic projection: the patellar ligament angle, the patellar ligament insertion angle, the angle of tibial translation measured by 2 different methods, and the linear distance between the points of CCL origin and insertion (DPOI). Additionally, a novel variable, DPOI ratio, was evaluated. Regarding radiographic positioning, tibial compression significantly changed most of the variables in the within-group comparison. The variable DPOI were not different with and without tibial compression in the group of healthy adult dogs but were different for dogs with CCL rupture. Thus, these are important parameters in the diagnosis of CCL rupture. In the analysis of a novel variable, DPOI ratio, dogs with CCL rupture could be distinguished from healthy dogs at a high level of specificity and sensitivity. DPOI ratio values above 1.18 were consistently indicative of CCL rupture, thus allowing for a precise radiographic diagnosis of the condition.

Return to Sport Following ACL Reconstruction With Slope-Correcting High Tibial Osteotomy in the Elite Athlete

Background: Increased posterior tibial slope is a strong predictor of anterior cruciate ligament (ACL) graft re-injury. A concomitant slope-reducing high tibial osteotomy (HTO) has been suggested to decrease re-tear risk in these cases although little is known regarding outcomes following ACL reconstruction with HTO, especially in elite athletic patients. Indications: A 19-year-old National Collegiate Athletics Association (NCAA) Division 1 running back presented with an ACL tear, lateral meniscus tear, and posterior tibial slope of 19° (case 1). A 19-year-old NCAA Division 1 soccer forward presented with an ACL graft re-tear and posterior tibial slope of 21° (case 2). Technique: Anterior closing wedge HTOs were performed along with a primary ACL reconstruction with quadriceps tendon autograft (case 1) and a revision ACL reconstruction with quadriceps tendon autograft (case 2). Following the arthroscopic procedures, an anterior approach was used to insert the first guide wire distal to the patellar tendon insertion from anterior to posterior aiming toward the posterior curve of the tibia. A second guide wire was placed at the previously templated distance. The osteotomy was then performed utilizing a saw and then osteotome. The reduction was performed by gently lifting the ankle anteriorly and applying axial pressure, and a new posterior tibial slope was calculated. After the osteotomy site was reduced, a preliminary reduction was performed by applying a clamp to both wires followed by placing a wire across the osteotomy site aiming from anterolateral to posteromedial. An anterolateral proximal tibial plate was applied, as well as a lag screw across the osteotomy site. Results: At 6 months after surgery, case 1 demonstrated &gt;90% Limb Symmetry Indices (LSI) with quadriceps strength, single leg hop tests, and change of direction tests. At 12 months after surgery, case 2 demonstrated &gt;90% LSI with all functional testing and competed in 17 games. Both patients returned to preinjury performance metrics including top speed and vertical jump height. No significant postoperative complications or instability was observed. Discussion/Conclusion: Primary or revision ACL reconstruction with HTO shows potential to assist athletes in returning to high-level sport while reducing posterior slope. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

A mismatch of planning and achieved tibial plateau angle in cranial closing wedge surgery: An in silico and clinical evaluation of 100 cases.

(1) To determine whether Oxley's modified cranial closing wedge osteotomy (CCWO) results in a tibial plateau angle (TPA) of 5° in silico, (2) compare in silico to clinical postoperative TPA and (3) determine the impact of ostectomy distalization in silico. Cross-sectional retrospective radiographic in silico study. A total of 100 stifle radiographs; 90 dogs (small ≤25 kg = 84; large >25 kg = 16). Tibial plateau angles were measured preoperatively (TPAPre ), after in silico planning (TPAPlan ), and postoperatively (TPAPost ). Virtual ostectomies were evaluated for plate fit. Postoperative ostectomy position was measured. Virtual ostectomies were performed 5/7.5/10/15 mm from the patellar tendon insertion in 10 dogs from each preoperative TPA category (≤20°/21-25°/ 26-30°/31-35°/>35°). Comparisons for TPAPre , TPAPost , and TPAPlan were made between small and large dogs, and the outcome to the target 5° between TPA categories and ostectomy positions. Mean ± SD TPAPre was 28.6 ± 6.2° and higher in small than large dogs. Mean TPAPlan was 7.6 ± 2.7°. Plate fit was appropriate in all. In silico, TPAs were greater than 5° except for cases with TPAPre > 35°. Median TPAPost was 5.5° (-4-21) and was higher in small (7°) than large (4.5°) dogs. Postoperative ostectomy position was more distal than Oxley's guidelines. When distalized >7.5 mm in silico, the magnitude of under-correction increased. Oxley's modified CCWO did not result in TPA of 5° in most cases. Ostectomy distalization exacerbated under-correction. Current guidelines should be modified to achieve 5° TPA postoperatively.

Poster 294: Patellar Tendon Insertion is Not Distalized following Tibial Tubercle Osteotomy with Distalization

Objectives: Patella alta is a common anatomic risk factor in patients with patellofemoral instability and/or patellofemoral cartilage lesions, occurring in nearly 25% of these patients. Distalization tibial tubercle osteotomy (TTO) is effective in patients with patella alta in association with patellofemoral instability and cartilage lesions. Prior studies have suggested that increased patellar tendon length itself is a risk factor for recurrent patellofemoral instability, and have proposed the addition of a patellar tendon tenodesis via placement of a suture anchor proximal to the distalization TTO. However, concerns regarding increased patellofemoral cartilage stresses with addition of patellar tendon tenodesis have limited its adoption. The purpose of this study was to evaluate patellar tendon length and alignment parameters on preoperative and postoperative MRI and to evaluate patient reported outcomes (PROs) following distalization tibial tubercle osteotomy (TTO) without patellar tendon tenodesis in patients with patella alta. Methods: We conducted a retrospective review of 20 adult patients who underwent distalization TTO for patellar alta at our institution (December 2014-August 2021). All patients underwent preoperative and postoperative magnetic resonance (MR) imaging of the affected knee. Distalization TTO utilized a wedge-shaped osteotomy measuring ˜5cm in length and was fixed with two 4.5mm bicortical fully threaded screws following TT transfer. Caton-Deschamps (CDI), axial and sagittal TT-TG indices1, patellar tendon length and distances from tibial plateau to patellar tendon insertion and tibial tubercle were assessed (Figure 1). PROs included IKDC Subjective Knee Evaluation, KOOS Quality of Life Form, Kujala Anterior Knee Pain From, and Veterans RAND 12 Item Mental (VR12-MH) and Physical Health (VR12-PH) Surveys. Clinical data, including demographics, complication and perioperative data, was obtained from preoperative and postoperative charts in our electronic medical record. Results: Average age at time of surgery was 27.4 years (range: 14 – 42 years) and all patients were female. Average BMI was 24.9 +/- 4.4 kg/m2. Eleven patients (55%) were diagnosed with isolated patellofemoral cartilage lesions, four patients (20%) were diagnosed with patellofemoral instability without associated cartilage lesions and five patients (25%) were diagnosed with both instability and cartilage lesions. At the time of TTO distalization, eleven patients (55%) underwent matrix-induced autologous chondrocyte implantation (MACI), nine patients (45%) underwent MPFL reconstruction, four patients (20%) underwent lateral release/lengthening, and three patients (15%) underwent osteochondral allograft (OCA) implantation. Fourteen patients (70%) underwent anteromedialization of the tibial tubercle in addition to distalization. Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11 (p &lt; 0.001), improved rotational alignment (axial TT-TG decreased from 14.3mm to 11.1mm (p = 0.018)) and anteriorization of the TT (sagittal TT-TG increased from -4.3mm to -1.4mm (p = 0.037)) following distalization TTO. Distance from the tibial plateau to the PT insertion decreased from 20.1mm preoperatively to 17.9mm postoperatively (p&lt; 0.020) and patellar tendon length decreased from 53.4mm preoperatively to 50.0mm postoperative (p &lt; 0.001). Average distalization was 6.4mm. IKDC scores increased from 37.1 to 60.5 (p = 0.011), KOOS QOL scores increased from 19.5 to 42.1 (p &lt; 0.001), Kujala scores increased from 50.9 to 70.6 (p = 0.018), VR12-MH scores increased from 52.7 to 59.2 (p = 0.024) and VR12-PH scores increased from 35.1 to 41.7 (p = 0.009). Of the patients with preoperative patellofemoral instability, there were no cases of recurrent instability postoperatively. Ten patients (50%) underwent elective removal of hardware of TTO screws at an average of 10.7 months. There were four (20%) complications in this cohort, with two cases (10%) of postoperative arthrofibrosis requiring manipulation under anesthesia, one case (5%) of postoperative MRSA infection of the MPFL graft and one case (5%) of tibial tubercle delayed union requiring bone grafting and revision fixation. Conclusions: Distalization TTO without patellar tendon tenodesis is an effective surgical technique for improving patellar height in patients with patella alta and patellofemoral instability and/or patellofemoral cartilage lesions, with improvements in radiographic parameters and PROs postoperatively. There were no cases of recurrent instability in this cohort. The patellar tendon insertion does not appear to be significantly distalized following distalization TTO, likely related to scarring of the patellar tendon just proximal to the osteotomy site postoperatively. Given the complexity of risk factors associated with patellofemoral instability and patellofemoral cartilage lesions, distalization TTO provides an additional tool for patient-specific surgical management, without the need for patellar tendon tenodesis.

Original surgical technique for the treatment of patellofemoral instability after failure of conservative treatment

IntroductionAcute patellar dislocation is a common but serious injury that can significantly impact a patient's functional prognosis. The objective of this retrospective study is to evaluate the clinical outcomes of arthroscopic medial patellofemoral ligament (MPFL) reconstruction and plication of the medial patellar retinaculum using suture anchors in adolescent patients with first-time acute patellar dislocation (APD) and MPFL insertion injury. HypothesisTightening repair of the medial retinaculum complex can result in favorable clinical and functional outcomes in this patient population. Materials and methodsA total of 84 adolescent patients with first-time APD and with an average age of 15.5 years (10-22) were included in the study. Of these patients, 61 (7 male and 54 female) underwent arthroscopic suture anchor plication for medial patellar retinaculum, while the other 23 were successfully treated non-operatively. Radiographic outcomes, including the congruence angle (CA), lateral patellofemoral angle (LPA), and patellar tilt angle (PTA), were evaluated preoperatively and at the last follow-up visit in the surgical group. Functional outcomes were assessed using the Lille Patello-Femoral Score, Lysholm Score, and Kujala Score at the same time points. In addition, the surgical and non-operative treatment success groups were compared in terms of both radiographic and functional outcomes. ResultsMean follow-up was 40.9 months (24–60). Fifty-nine knees showed excellent or good results postoperatively, 2 patients had a recurrent patellar subluxation. The Lille Patello-Femoral Score was 96.9±4.7 at the last follow-up. The subjective Lysholm Score and Kujala Score improved significantly, from 58.6 to 91.9 and from 60.4 to 88.9, respectively. The radiographic CA, LPA and PTA improved significantly, from 19.8±2.1° to –6.7±1.7°, from –7.4±2.2° to 5.7±1.8° and from 23.8±2.9° to 12.3±2.3°, respectively. There was no statistically significant difference in functional and radiographic assessments between the success with non-operative treatment group and the surgery group. ConclusionThe results of this study suggest that arthroscopic MPFL insertion reconstruction and plication using suture anchors, which is less invasive and improves patella stability, can lead to favorable clinical and functional outcomes in adolescent patients with first-time acute patellar dislocation and insertion injury. This treatment approach should be considered as a viable option for this patient population. Level of evidenceIV; monocentric retrospective descriptive study.

Manajemen Fisioterapi Pada Atlet Dengan Osgood-Schlatter’s Disease – Sebuah Studi Kasus

Background: Osgood-Schlatter (OSD) Including the most common injuries that occur during productive age, this condition occurs due to inflammation of the patellar tendon insertion at the tuberosity of the tibia. Osgood Schlatter usually occurs in children and adolescents who are active in sports, usually occurs in male adolescents aged 13-14 years and female adolescents aged 10-11 years. Purpose: Reducing pain in the right knee, reducing edema, maintaining muscle strength and increasing muscle mass M.Quadriceps, M.Hamstrings, M.Gastrocnemius, M.Gluteus, M.Adductor hip, M.Pectineus, M.Adductor longus, M. Adductor brevis, M. Adductor magnus, M. Gracilis. evaluated with 8 items sport scale. Methods: This study involved boys aged 12 years who experienced Osgood-schlatter. The exercise program was carried out for 3 weeks. Results: In this study, patients were followed up every week. The patient underwent physiotherapy sessions for 3 weeks. Patients are given measurements for muscle strength, increase in LGS, changes in segment circumference, and are obtained from the patient's ADL. Conclusion: In this study it can be concluded that after being given intervention for 3 weeks there were still no changes in Pain Level, Muscle Strength Level, Range of Joint Motion, Segment Circumference and Activity Daily Living in patients with the Osgood- Schalatter condition.

Differences of injury characteristics of medial patellofemoral ligament in acute lateral patellar dislocation and multiligament knee injuries.

The injury characteristics of medial patellofemoral ligament (MPFL) in multiligament knee injuries (MLKIs) and the differences of injury patterns of MPFL in MLKIs and acute lateral patellar dislocation (LPD) remain unclear. To explore the differences of injury characteristics of MPFL after acute LPD and MLKIs. Magnetic resonance images were prospectively analyzed in 219 patients after acute LPD or MLKIs. Statistical analyses of the injury patterns of MPFL were performed between LPD and MLKIs. The incidence of partial tear and complete MPFL tear in adolescent LPD and MLKIs were 40.3% and 48.4%, and 27.9% and 16.3%, respectively. Compared with LPD, MLKIs showed lower incidence rates of partial and complete MPFL tears (both P = 0). The MLKI subgroup showed lower incidence rates of MPFL tear at the patellar insertion (PAT), femoral attachment (FEM), and multiple-site of the MPFL (COM) (9.3%, 20.9%, and 14%) when compared with the LPD subgroup (45.2%, 24.2%, and 16.1%) (all P < 0.01). The incidence of partial tear and complete MPFL tear in adult LPD and MLKIs were 41.5% and 47.2%, and 24.6% and 16.4%, respectively. Compared with LPD, MLKIs showed lower incidence rates of partial and complete MPFL tears (both P = 0). The MLKI subgroup showed lower incidence rates of MPFL tear at PAT, FEM, and COM (8.2%, 18%, and 14.8%) when compared with the LPD subgroup (20.8%, 34%, and 30.2%) (all P = 0). Compared with LPD, MPFL tears are relatively uncommon in MLKIs. Even if MPFL tears occur, partial tears and femoral-sided tears are relatively more common.

When all is not good – managing an adolescent with Osgood Schlatter disease

Anterior knee pain in children above 10 years of age is a part of every orthopaedic surgeon OPD practice. Osgood-Schlatter disease is the most common cause in skeletal of immature athletic children. It is a condition, in which the patellar tendon insertion on the tibial tuberosity becomes inflamed. It tends to occur more commonly in boys and it occurs in the second decade of life ( 10-15 years). It is a self limiting condition and and occurs secondary to repetitive extensor mechanism stress activities such as jumping and sprinting. OSD is a clinical diagnosis, and only radiographic evaluation may be done to confirm the diagnosis. Pain level dictates overall treatment, and management includes symptomatic treatment with ice and NSAIDs, as well as activity modification. &amp; relative rest from inciting activities in association with lower extremities stretching exercises. In this paper we discuss the etiology, presentation, evaluation, and management of osgood schlatter disease. Keywords: osgood Schlatter disease , osteochondritis, anterior knee pain.

Impacts of tibial plateau levelling osteotomy on the tibial insertion of the medial collateral ligament of the canine stifle joint – A cadaveric study

ObjectiveThe aim of this study was to assess the potential consequences of tibial plateau levelling osteotomy (TPLO) for the medial collateral ligament (MCL) tibial insertion (TI) with a particular focus on the effects of the TPLO planning technique and of the size of saw blade. Study designEighty-six stifle joints were collected from 43 canine cadavers and dissected free of soft tissue to expose the MCL. The MCL insertion sites were first identified with Chinese ink on intact stifle joints, and then marked with radio-opaque barium sulfate after removal of the MCL. Mediolateral radiographs were made of each marked stifle joint and used for TPLO digital planning. For each stifle, planning the TPLO was performed by centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia in group 1, and at the top of the intercondylar tubercles in group 2. Whenever possible, two saw blade sizes were tested in each group. Measurements were taken after TPLO simulation to assess how the procedure would alter the MCL TI. ResultsIn group 1, the integrity of the MCL TI was affected by the TPLO planning in 87.2% of the cases with the small saw blade and in 59.3% of the cases with the large blade, and in group 2, in 94.2% of the cases with the small and 77.9% with the large saw blade. In group 1, the osteotomy line was located above the TI, completely severing the MCL in four cases versus in 11 cases in group 2, while severing occurred in 14/15 cases with the small saw blade. ConclusionDuring TPLO, the osteotomy line transected the MCL TI in the majority of dogs. Centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia and using the largest saw size that preserves tibial tuberosity and patellar tendon insertion seems to be the best way to preserve the MCL TI as much as possible. Further research is needed to evaluate the clinical impact of MCL TI transection.

Precise Patellar Tendon Insertion Protection and Osteotomy Surface Advantage of Transtibial Tuberosity-High Tibial Osteotomy.

Medial opening wedge high tibial osteotomy (HTO) is successful in the treatment of knee osteoarthritis with medial compartment stenosis and tibial varus deformity, but patella infera is the main complication. This study aims to design a new medial tibial open osteotomy scheme, transtibial tuberosity-high tibial osteotomy (TT-HTO), which can fully protect the patellar tendon insertion. In addition, the area of the osteotomy surface and wedge volume were evaluated in TT-HTO, biplanar distal tibial tuberosity osteotomy (biplanar-DTO), and uniplanar-DTO to evaluate the potential advantages of this technology in bone healing. The tibial tubercle was divided into four equal sections from proximal to distal, which were defined as zones A, B, C, and D. From September to December 2020, the imaging examinations of 200 patients (95 males and 105 females) with a mean age of 40.6 years (range 19-60 years) were evaluated to observe the zonation of the tibial tubercle where the insertion of the patellar tendon is located. Then, 59 patients (23 males and 36 females) with a mean age 59.6 years (range 43-77 years), for a total of 69 knees (32 right and 37 left), who underwent routine knee surgery were observed and verified. According to the position of the patellar tendon insertion, TT-HTO was designed. Fifteen tibial sawbones were divided equally into three groups: TT-HTO; biplanar-DTO; and uniplanar-DTO. The total area of the osteotomy surface was compared using the graph paper method. The wedge volume at wedge heights of 10 mm was compared among osteotomy types using the plasticine Archimedes principle. One-way repeated-measures analysis of variance was used to compare the total area of the osteotomy surface and the wedge volume. The osteotomy line of TT-HTO passes through the boundary point of zones B and C of the tibial tubercle to fully protect the insertion point of the patellar tendon. The total area of the osteotomy surface in TT-HTO and biplanar-DTO was significantly larger than that in uniplanar-DTO (P < 0.05). The wedge volume in uniplanar-DTO was significantly smaller than that in TT-HTO and biplanar-DTO (P < 0.05). No significant differences in the osteotomy surface and the wedge volume were identified between TT-HTO and biplanar-DTO. TT-HTO can protect the patellar tendon insertion and avoid postoperative patella infera. The osteotomy surface is large and located in an area of cancellous bone, which ensures its good healing characteristics.

27 Single center inception cohort of enthesitis-related arthritis: spectrum of characteristics, course and treatment approaches

BackgroundEnthesitis-related arthritis (ERA) accounts for ∼10% to 20% of juvenile idiopathic arthritis (JIA) cases. Application of adult data to children with ERA is not ideal as less severe spinal involvement and more pronounced enthesitis and peripheral arthritis are present in children. Therefore, it is very important to conduct research that focuses specifically on the ERA population.ObjectivesThis study aimed to present an ERA inception cohort and determine which entheses and joints are most commonly affected, course of the disease and treatment approaches.MethodsMedical records of 546 patients with JIA who met each of the International League of Associations for Rheumatology (ILAR) criteria were evaluated retrospectively. An inception cohort of children with ERA who were diagnosed at Istanbul Faculty of Medicine between December 2020 and April 2022 was included. Patient characteristics were summarized by median and interquartile range (IQR) for continuous variables and frequency and percentage for categorical variables. P values <0.05 were considered statistically significant. All analyses were performed using SPSS statistical software version 28.ResultsThere were 34 newly diagnosed ERA patients. Sixty percent were male, and the median age at the onset of the disease was 11.5 years (interquartile range [IQR] 9–14.8 years). The majority of the group met the ILAR criteria for a diagnosis of ERA at the first pediatric rheumatology visit (n = 29 [85.2%]), with 5 subjects (14.7%) meeting the criteria at the second visit. Twenty-three (69 %) subjects had enthesitis and arthritis at the time of diagnosis. The median number of tender entheses at presentation was 2 (IQR 0–4), and 20 subjects (58%) had at least 1 tender enthesis. The most frequent enthesitis were located on the patellar ligament insertion at the inferior pole of the patella, the plantar fascial insertion at the calcaneus, the Achilles tendon insertion at the calcaneus, and the plantar fascial insertion at the metatarsal heads. Fifty-five (19)% of patients had symmetric enthesitis. The most commonly affected joints were the sacroiliacs, knees, and ankles. Medication use varied significantly across sites for children with peripheral arthritis (p< 0.001), but not for sacroiliitis or enthesitis only. Nonsteroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs were the most commonly prescribed treatments, with anti-TNF agents primarily being initiation for sacroiliitis. HLA-B27 positivity was associated with male sex, higher active joint count, sacroiliitis, and higher disease activity at disease onset. The Juvenile Spondyloarthritis Disease Activity Index (JSpADA) was significantly higher in those who were HLA-B27-positive than in those who were HLA-B27-negative (p = 0.03). Those who were HLA-B27-positive were more likely to develop arthritis after the age of 6 years (p< 0.01).ConclusionEither the observed heterogeneity in clinical presentation may result from differences in patient populations or from differences in the way ILAR criteria are applied. Most children have a pauciarticular onset and lower extremity enthesitis is common when ERA diagnosed.

A Comprehensive Description of the Lateral Patellofemoral Complex: Anatomy and Anisometry

Background: The lateral patellofemoral complex (LPFC) is an important stabilizer of the patella composed of the lateral retinacular structures including the lateral patellofemoral ligament (LPFL), the lateral patellomeniscal ligament (LPML), and the lateral patellotibial ligament (LPTL). While the isolated anatomy of the LPFL has been previously described, no previous study has investigated the entirety of the LPFC structure, length changes, and radiographic landmarks. An understanding of LPFC anatomy is important in the setting of LPFL injury or previous lateral release resulting in iatrogenic medial instability requiring LPFC reconstruction. Purpose: To both qualitatively and quantitatively describe the anatomy and length changes of the LPFC on gross anatomic dissections and standard radiographic views. Study Design: Descriptive laboratory study. Methods: Ten nonpaired cadaveric specimens were utilized in this study. Specimens were dissected to identify distinct attachments of the LPFL, LPML, and LPTL. Ligament lengths, footprints, and centers of each attachment were described with respect to osseous landmarks using a 3-dimensional coordinate measuring device. Ligament length changes were also assessed from 0° to 90° of flexion. Radiopaque markers were subsequently utilized to describe attachments on standard anteroposterior and lateral radiographic views. Results: The individual elements of the LPFC were identified in all specimens. The LPFL patellar attachment had an average total length of 22.5 mm (range, 18.3-27.5 mm), involving a mean of 59% (range, 50%-75%) of the sagittal patella. Based on the average patellar size, a mean of 63% of the LPFL attached to the patella, and the remainder (11.1 ± 1.4 mm) inserted into the patellar tendon. The femoral attachment of the LPFL had a mean maximum length of 24.4 ± 4.3 mm. The center of the LPFL femoral attachment was a mean distance of 13.5 ± 3.2 mm anterior and distal to the lateral epicondyle. The LPFL demonstrated significant shortening, especially in the first 45° of flexion (7.5 ± 5.1 mm). In contrast, the LPTL (5.5 ± 3.0 mm) and LPML (10.0 ± 3.3 mm) demonstrated significant shortening from 45° to 90°. On lateral radiographs, the center of the femoral attachment of the LPFL was a mean total distance of 19.2 ± 7.2 mm from the lateral epicondyle. Conclusion: The most important findings of this study were the correlative anatomy of 3 distinct lateral patellar ligaments (LPFL, LPML, and LPTL) and their anisometry through flexion. All 3 components demonstrated significant shortening during flexion. The quantitative and radiographic measurements detailed the LPFL osseous attachment on the patella; soft tissue attachment on the patellar tendon; and finally, the osseous insertion on the femur distal and anterior to the lateral epicondyle. Similarly, the authors documented the meniscal insertion of the LPML and defined a patellar insertion of the LPTL and LPML as a single attachment. These data allow for reproducible landmarks to aid in the understanding and reconstruction of the lateral patellar restraints. Clinical Relevance: The data produced from this investigation provide a comprehensive description of these 3 lateral patellar stabilizers (LPFL, LPML, LPTL). These data can be used intraoperatively to facilitate anatomic reconstructions of the lateral patellar stabilizers.

Aging and entheses: An ultrasonographic probing of degenerative enthesopathy in a cohort of 147 healthy subjects.

To investigate the prevalence and features of degenerative enthesopathic changes in a large cohort of healthy individuals by musculoskeletal ultrasound (MSUS) and their relation to age and other demographic features. In this cross-sectional study, 147 healthy subjects (1470 entheses) were examined by MSUS according to the Outcome Measures in Rheumatology guidelines: Achilles tendon, plantar fascia, patellar, and quadriceps insertions of both lower limbs. The mean age (±SD) of the participants was 43.68 (±14.53) years and 57.1% were female. Enthesopathy has been detected in at least 1 area in 113 subjects (76.87%). Thickening (21.6%) and hypoechogenicity (15.3%) were the most frequent inflammatory findings while enthesophyte (10.13%) was the most prevalent structural one. Age and male gender were significantly correlating with inflammatory (rs =.341, P=.001/r=.310, P=.001), structural (rs =.354, P=.001/r=.166, P=.04) and total scores (rs =.406, P=.001/r=.302, P=.001). More inflammatory changes were noticed in the age group 36-55years. Body mass index had a positive correlation with inflammatory (rs =.290, P=.001) and total scores (rs =0.298, P=.001) but not with structural lesions (rs =.154, P=.062). Thickening, hypoechogenicity, cortical irregularities, and enthesophytes are frequent degenerative features of enthesopathy. These findings need to be redefined to be more specific for spondyloarthritides. Enthesopathy should be interpreted with caution in the light of the clinical picture, especially in elderly and obese male patients.