Patellar Tendon Insertion Research Articles

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.

Histological differences in cartilage layer growth at various tendon and ligament insertions in rabbits.

Objectives: Histological differences in cartilage layer growth in Achilles tendon (AT), quadriceps tendon (QT), patellar tendon (PT), and anterior cruciate ligament (ACL) insertion are unclear. Therefore, this study aimed to investigate the differences in cartilage layer growth in AT, QT, PT, and ACL insertions. Materials and Methods: Forty-eight male Japanese white rabbits were used. Six animals were euthanized at different stages (day 1 and 1, 2, 4, 6, 8, 12, and 24 weeks). Safranin O-stained glycosaminoglycan (GAG) production area, chondrocyte count, and insertion width were investigated. Results: A two-way analysis of variance (ANOVA) revealed a significant difference in the main effects of time and insertion for all parameters. In addition, the time × insertion interaction was significant. Multiple comparisons showed a significant difference between the ACL insertion and all other variables; however, the GAG production area was not significantly different for the QT, PT, and AT insertions. AT insertions were significantly different from all other groups; however, the number of chondrocytes and insertion width were not significantly different for ACL, QT, and PT insertions. Conclusion: Cartilage layer growth differed between the AT, QT, PT, and ACL insertions. The differences between the insertions may also be due to the differences in their structures, locations, and mechanical environments.

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.

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.

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.

18F-sodium fluoride PET-CT visualizes both axial and peripheral new bone formation in psoriatic arthritis patients

PurposeAs bone formation is associated with psoriatic arthritis (PsA), positron emission tomography (PET) using a 18F-Fluoride tracer may enable sensitive detection of disease activity. Our primary aim was to determine the feasibility of whole-body 18F-sodium fluoride PET-CT in clinically active PsA patients to depict new bone formation (as a reflection of disease activity) at peripheral joints and entheses. Our secondary aim was to describe 18F-sodium fluoride findings in the axial skeleton.MethodsSixteen patients (female 10/16, age 50.6 ± 8.9 years) with PsA fulfilling CASPAR criteria or with a clinical diagnosis of PsA according to the treating rheumatologist and with ≥ 1 clinically active enthesitis site were included. Of each patient, a whole-body 18F-sodium fluoride PET-CT scan was performed. All scans were scored for PET-positive lesions at peripheral joints, enthesis sites and the spine. Clinical disease activity was assessed by swollen/tender joint count 44, enthesitis according to MASES and SPARCC scores.ResultsOut of 1088 evaluated joints, 109 joints showed PET enhancement, mainly in the interphalangeal and metatarsal joints of the feet (14/109, 12.9%) and the distal interphalangeal joints of the hands (14/109, 12.9%). PET positivity was found at 44/464 enthesis sites, mainly at the patella tendon insertion (11/44, 25%) and quadriceps tendon insertion (10/44, 22.7%). Of the PET-positive joints and enthesis sites, respectively 18.2% and 29.5% were clinically positive; 81.8% and 70.5% of the PET-positive joints and entheses respectively were clinically asymptomatic. In 11 patients, ≥ 1 axial PET-positive lesion was observed, mainly in the cervical spine.ConclusionsNew molecular bone formation was observed on 18F-sodium fluoride PET-CT scans, in all domains in which PsA disease activity can be observed, with a substantial part showing no clinical symptoms.Clinical trial registrationEudraCT: 2017-004,850-40, registered on 13 December 2017.

Musculoskeletal Ultrasound of the Patellar Tendon in Adolescent Athletes

Background:Patellar tendinopathy is a common chronic condition caused by mechanical loading that leads to patellar tendon (PT) degeneration, with an estimated incidence of 13% across all sports in adolescents. Musculoskeletal ultrasound (MSK-US) evaluation is becoming more common in the diagnostic process, but normative data are extremely rare for the adolescent population. These normative data are needed to aid in proper interpretation of the MSK-US image.Purpose:The purpose of this study was to determine standard reference values for thickness, width, and cross-sectional area (CSA) of the PT using MSK-US in asymptomatic adolescent athletes.Methods:IRB approval, parental consent, and athlete assent were obtained prior to data collection. Bilateral PT were scanned using a portable US unit with a 12-4MHz linear array transducer. Long axis images were captured at the apex and 1cm distal to the patella, 1 cm proximal to the insertion and at the PT insertion (Figure 1a & 1b). Short axis images were captured 1 cm proximal and distal to the attachments. PT thickness, width, and CSA were measured using ImageJ by a single evaluator. Additional exploratory analyses were also conducted.Results:Seventy-one adolescent athletes (27 males, 44 females) between 11-18 years old (13.8 ±1.8 years) volunteered. Mean values for PT thickness, width, and CSA are found in Table 1. Significant differences in PT thickness and CSA between sex were identified at each measurement location (P<.05), with males ranging 4.0-9.9 mm thicker than females. PT width was not significantly different proximally or distally. The left proximal PT was significantly wider than right (P<.0001), but no other side differences were found. Lastly, significant weak positive correlations were present in distal tendon CSA with height (left PT: r(52)=.348, P=.014, right PT: r(49)=.369, P=.007) and weight (left PT: r(50 )=.290, P=.041). There was no correlation with age.Conclusion:These data represent one of the largest healthy cohorts of adolescent athletes from which normative data have been collected. This preliminary analysis reveals some interesting trends, such as the thickness of the PT is greatest at the insertion and origin, while thinner at mid-tendon, with the insertion the thicker of the two. Age was not correlated with PT size, but distal PT CSA was larger with taller and heavier individuals. These data will contribute to the paucity of adolescent PT MSK-US data, which should aid clinicians in interpretation, diagnostic accuracy, and management of active adolescent patients with patellar tendinopathy.Figure 1.Long axis US images of the proximal (a) and distal patellar tendon (b)Table 1.Patellar tendon means and standard deviation

Extensor Mechanism-Sparing Technique for Management of Proximal Tibia Sarcoma Resection: A Case Series Study

The proximal tibia is one of the most challenging anatomic sites for resection of large bone tumors, due to the vicinity of the extensor mechanism. Here, we report outcomes of a novel radical resection technique which preserves the extensor apparatus. 8 patients were operated between 2001 and 2011 for large sarcomas with high-grade tibial localization. Six were giant cell tumor of bone histology (GCTB; defined as severe bone destruction and soft tissue extension) and two chrondrosarcoma at surgical grade G1, but with double localization in tibia and femur. Primary bone tumors and recurrences were treated with novel multiplanar resection technique avoiding removal of the tibial tuberosity and the patella tendon insertion, preserving extensor mechanism. In all cases, curettage and borage were not indicated due to extensive lesion size. Radical resection of the lower extremity (2 femurs and 8 tibias) yielded wide margins (R0) and patients were evaluated at 10 years of follow up. The average post operative Musculoskeletal Tumor Society (MSTS) score was 26.87 points (range: 23-29). All patients reached full passive and active extension and the maximum active flexion was 108.75° (range: 90°-120°). At the last follow-up (mean: 121.8 months), all patients and implants survived; no local infection, recurrence, metastasis, or relevant complications occurred. This surgical technique therefore appears to provide a safe treatment option when wide surgical margins are possible, and preserving the integrity of the extensor mechanism may improve the clinical outcome.

Differences in the Development of Fibrocartilage Layers in the Quadriceps Tendon and Patellar Tendon Insertions in Rabbits: A Quantitative Study.

Background:Differences in the development of fibrocartilage layers in quadriceps tendon (QT) and patellar tendon (PT) insertion sites are unclear. Because the mechanical environments for the QT and PT are different, the development of the QT and PT insertions may differ.Purpose:To investigate differences in the development of fibrocartilage layers in the QT and PT insertion sites in rabbits through use of quantitative morphometric evaluations.Study Design:Descriptive laboratory study.Methods:This study included 54 male Japanese White rabbits. Animals were euthanized at ages 1 day and 1, 2, 3, 4, 6, 8, 12, and 24 weeks (n = 6 for each age). Chondrocyte number, proliferation, apoptosis, sex-determining region Y box 9 (Sox9)–positive rates, safranin O–stained glycosaminoglycan (GAG) areas, tidemark length, insertion width, and patellar length were evaluated and compared with the same parameters at age 24 weeks and between QT and PT insertion sites.Results:Chondrocyte proliferation was low up to age 2 weeks for QT insertion and low up to 1 week for PT insertion. Chondrocyte apoptosis was high at 1 day and Sox9 expression was low up to 1 week for PT insertion. Sox9 expression was higher in QT than in PT insertion at age 12 weeks. The high chondrocyte count continued to age 1 day in PT insertion and up to 6 weeks in QT insertion. The chondrocyte number was higher in QT than in PT insertion at age 2 weeks. The period of thicker GAG lasted from 2 to 8 weeks in PT insertion and from 1 to 12 weeks in QT insertion. GAG thickness in QT insertion was higher than in PT insertion at age 4 and 12 weeks.Conclusion:Development of fibrocartilage layers in QT and PT insertion sites was completed at age 24 weeks in rabbits. However, the period of high chondrocyte count and period of thicker GAG were longer in QT than in PT insertion up to 12 weeks.Clinical Relevance:Development of fibrocartilage layers in QT and PT insertions differed in rabbits. Our results may contribute to the development of appropriate treatments based on age and the development of methods for regeneration of the insertion.

Relationship Between Lateral Patellar Stability and Tibial Tubercle Location for Varying Patellofemoral Geometries.

The geometry of the patellofemoral joint affects function and pathology. However, the impact of trochlear groove depth on treatments for patellar instability and pain is not clear. Tibial tubercle osteotomy is a common surgical intervention for patellar instability where the tibial insertion of the patellar tendon (PT) is translated to align the extensor mechanism and stabilize the joint. The aim of this work was to investigate the interaction between trochlear groove depth and PT insertion and their effect on patellar stability. Patellofemoral geometry was modified based on a statistical shape model to create knees with a range of trochlear groove depths. A Monte Carlo approach was used and 750 instances of a musculoskeletal model were generated with varying geometry and anterior and medial transfer of the PT. Stability was assessed by applying a lateral perturbation force to the patella during simulation of overground walking. In knees with deep trochlear grooves, a medialized PT increased stability. However, in knees with shallow trochlear grooves, stability was maximized for tendon insertion ∼1 mm medial to its neutral location. This PT insertion also corresponded to the best alignment of the patella in the trochlear groove in these knees, indicating that good alignment may be important to maximizing stability. Anterior PT transfer had minimal effect on stability for all geometries. A better understanding of the effects of articular geometry and tubercle location on stability may aid clinicians in patient-specific surgical planning.

A Knee Size-Independent Parameter for Malalignment of the Distal Patellofemoral Joint in Children.

Introduction Patellar instability (PI) is a common finding in children. Current parameters describing patellofemoral joint alignment do not account for knee size. Additionally, most parameters utilize joint-crossing tibiofemoral landmarks and are prone to errors. The aim of the present study was to develop a knee size-independent parameter that is suitable for pediatric or small knees and determines the malpositioning of the distal patellar tendon insertion solely utilizing tibial landmarks. Methods Sixty-one pediatric knees were included in the study. The tibial tubercle posterior cruciate ligament distance (TTPCL) was measured via magnetic resonance imaging (MRI). The tibial head diameter (THD) was utilized as a parameter for knee size. An index was calculated for the TTPCL and THD (TTPCL/THD). One-hundred adult knees were analyzed to correlate the data with a normalized cohort. Results The THD was significantly lower in healthy females than in males (69.3 mm ± 0.8 mm vs. 79.1 mm ± 0.7 mm; p < 0.001) and therefore was chosen to serve as a knee size parameter. However, no gender differences were found for the TTPCL/THD index in the healthy adult study cohort. The TTPCL/THD was significantly higher in adult PI patients than in the control group (0.301 ± 0.007 vs. 0.270 ± 0.007; p=0.005). This finding was repeated in the PI group when the pediatric cohort was analyzed (0.316 ± 0.008 vs. 0.288 ± 0.010; p=0.033). Conclusion The TTPCL/THD index represents a novel knee size-independent measure describing malpositioning of the distal patellar tendon insertion determined solely by tibial landmarks.

The Relationship Between Physical Examination and Ultrasonography of Large Entheses of the Achilles Tendon and Patellar Tendon Origin.

To investigate the relationship between physical examination (PE) and sonographic features of enthesitis, based on anatomical sites. The analysis was done using merged raw data of 3 studies on 2298 entheses. Patients with clinical Achilles enthesitis had more abnormalities on ultrasound (US): hypoechogenicity, p < 0.001; thickening, p = 0.001; Doppler signals, p = 0.002; and erosions, p = 0.02. The patellar tendon origin also correlated with PE but distal patellar tendon insertion and plantar aponeurosis were uncoupled from the US. The relationship between clinical and sonographic findings for large entheses is dependent on the anatomical site. For the patellar tendon origin and Achilles entheses, PE is significantly linked to US findings.

Relationship between Tibial conformation, cage size and advancement achieved in TTA procedure

BackgroundPrevious studies have suggested that there is a theoretical discrepancy between the cage size and the resultant tibial tuberosity advancement, with the cage size consistently providing less tibial tuberosity advancement than predicted. The purpose of this study was to test and quantify this in clinical cases. The hypothesis was that the advancement of the tibial tuberosity as measured by the widening of the proximal tibia at the tibial tuberosity level after a standard TTA, will be less than the cage sized used, with no particular cage size providing a relative smaller or higher under-advancement, and that the conformation of the proximal tibia will have an influence on the amount of advancement achieved.ResultsOne hundred sixty-four dogs met the inclusion criteria. The mean percentage under-advancement was 15.5%. All dogs had an advancement less than the stated cage size inserted. An association between the proximal tibial tuberosity angle (increased in cases with low patellar tendon insertion), and percentage under-advancement was found, with an increase of 0.45% under-advancement for every 1 degree increase in angle a (p = 0.003). There was also evidence of a difference between the mean percentage under-advancement in breeds (p = 0.001) with the Labrador having the biggest under-advancement. Cage size (p = 0.83) and preoperative tibial plateau angle (p = 0.27) did not affect under-advancement.ConclusionsThe conformation of the tibial tuberosity and therefore the relative cage positioning have an impact on mean percentage under-advancement of the tibial tuberosity after standard TTA. In all evaluated cases, the advancement of the tibial tuberosity was less than intended by the cage size selected.

Modification of a sonographic enthesitis score to differentiate between psoriatic arthritis and young healthy volunteers

Objectives: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison.Method: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI.Results: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002).Conclusions: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volunteers. After recoding of PD severity and excluding thickness of knee entheses, marked differences between PsA patients and healthy controls were observed.