Patellofemoral Arthrosis Research Articles

EFFECTS OF SIMULATED FIXED FEMORAL ROTATION ON THE PATELLOFEMORAL JOINT: IN VITRO AND IN VIVO BIOMECHANICAL ASSESSMENT IN CANINES

The quantitative effects of fixed femoral rotation on the patellofemoral joint were assessed in canines in vitro and in vivo. For the in vitro study, ten canine knees were examined in neutral and 30 degrees of internal and external fixed femoral rotations. Fuji film was inserted into the patellofemoral joint and quadriceps loading was simulated at 60 and 90 degrees of knee flexion. There was significant increase in patellofemoral contact pressures on the contralateral facets of the patella with 30 degrees of fixed femoral rotation at both knee flexion angles (p < 0.05). For the in vivo study, 12 skeletally mature mongrel dogs were subjected to either internal or external bilateral femoral rotational deformity of 30 degrees. Three animals served as controls. Biomechanical evaluation of the articular cartilage showed a statistically significant decrease for both the unrelaxed and relaxed apparent shear modulus at six months for both internal and external femoral rotations (p < 0.05) in comparison to the control. In vivo results from fixed femoral rotation on the patellofemoral joint correlate with that expected from in vitro biomechanical results. The results from this study suggest that rotational deformity of the femur should be corrected within six months to prevent patellofemoral joint arthrosis.

Anteromedialization of the Tibial Tubercle for Treatment of Patellofemoral Malpositioning and Concomitant Isolated Patellofemoral Arthrosis

Anteromedialization of the Tibial Tubercle for Treatment of Patellofemoral Malpositioning and Concomitant Isolated Patellofemoral Arthrosis

OPEN OR ARTHROSCOPIC LATERAL RELEASE: Indications, Techniques, and Rehabilitation

Careful patient selection, accurate surgical technique, and careful postoperative rehabilitation are all equally important to success in lateral release surgery. Whether the surgery is performed by open or arthroscopic technique, one must release all layers of the retinaculum, spare the vastus lateralis, extend the release far enough distally, check intraoperative patellar mobility, and obtain absolute hemostasis. Postoperative rehabilitation must stress pain control, early quadriceps contraction, patellar mobility, and knee motion. With attention to these details, successful lateral release surgery is likely in most patients with pathologic lateral patellar tilt and minimal patellofemoral arthrosis.

Pain reduction after anteromedial displacement of the tibial tuberosity: 5-year follow-up in 21 knees with patellofomoral arthrosis.

We performed anteromedial displacement of the tibial tuberosity in 21 knees of 16 patients having patellofemoral arthrosis with lateral subluxation. The mean age of the patients was 53 (47-65) years and they were followed for 5(2-13) years. Preoperatively, all knees were painful on descending or ascending stairs; pain was relieved after operation in 20. Retropatellar crepitations disappeared in 2 of 20 knees, but retropatellar pain when squeezing the patella against the femur disappeared in 16 of 17 knees. Patellar subluxation diminished in all knees.

Double modified Hauser procedure: a long-term follow-up

A long-term follow-up of 20 patients (23 knees) who had undergone the double modified Hauser (DMH) procedure was conducted. This procedure, a modification of a previously reported distal patellar realignment procedure 1, consists of medial and proximal implantation of the tibial tubercle to correct abnormal tracking with simultaneous anterior advancement (Maquet principle) to reduce contact pressures. All but two patients had undergone failed surgeries in the past and required operative intervention because of repeated patellar dislocations with severe anterior knee pain or, in five cases, severe pain due to advanced patellofemoral arthrosis. At an average follow-up of 11.6 years, 16 20 patients were satisfied with the result, two were unsure and two were dissatisfied. Recurrent dislocations occurred in four patients. At rest, 11 23 knees were occasionally painful, while 20 knees were occasionally painful when walking. Of 20 knees X-rayed, degenerative changes were found in 12, of which five had undergone patellectomy for intractable anterior knee pain. While this procedure is not recommended as a primary operation to correct tracking, the authors feel it offers theoretical advantages over the Maquet procedure for salvage purposes when arthroscopic lateral release has failed.

Rehabilitation of the Allograft Reconstruction

A series of prospective studies have been performed using allograft tissue for anterior cruciate ligament (ACL) reconstruction. This type of procedure has been shown to effectively control joint displacement and increase overall patient function in a specific patient population. In considering the use of allograft tissue, the surgeon must take into account the indications and contraindications as well as graft preparation and possible immune response. The current clinical trend is utilization of allograft tissue for patients who have previously failed autograft surgery, have patellofemoral arthrosis, or have a long-standing chronic ACL deficiency. The rehabilitation process for these types of patients is very similar to our approach in the autograft patient. It is important for the clinician to facilitate an early motion program after surgery, early exercise protocols, and early weight bearing. However, as in any protocol, careful evaluation is critical. Three different studies reported by our group have shown the allograft to be successful in controlling joint displacement. On testing with the KT-1000 arthrometer, 69 percent of acute repairs had less than 3 mm of anterior posterior displacement; 26 percent of these patients had only 3-5 mm of anterior displacement compared to the contralateral knee. A second study of chronic anterior cruciate ligament patients showed 54 percent had under 2.5 mm of anterior displacement and 34 percent had 3-5 mm of anterior displacement when compared to the contralateral knee. With effective implementation of a rehabilitation program, only 5 percent of our acute and chronic patients developed a motion complication, and only 9 percent had patellofemoral complaints. Using a strict rating system, the overall rating of these patients showed that 89 percent were in the excellent to good range, which allowed them to once again participate in recreational or competitive sports. Only 11 percent had a fair to poor result; 50 percent of that group chose not to return to sporting activity for nonknee related causes. These studies have shown that allograft ligament reconstructive techniques are effective and improve functional ability in the chronic anterior cruciate ligament patient. Use of these tissues should, however, be on a selective basis. Caution must be used by the physician when using these tissues, and the physical therapist must recognize that the protocol for postoperative management is essentially the same as for the autograft techniques. J Orthop Sports Phys Ther 1992;15(6):294-302.

The Early Diagnosis and Treatment of Developmental Patella Infera Syndrome

Developmental patella infera and associated arthrofibrosis after knee surgery require prompt recognition and treatment. The condition develops because of contracture of peripatellar tissues, fatpad tissues, and quadriceps weakness, and may rapidly progress to permanent patella infera and disabling patellofemoral arthrosis. Case studies for five patients with acute developmental patella infera are described. All patients required an early arthroscopic release of contracted tissues. To establish normal right to left patellar, vertical-height ratios, lateral roentgenograms were obtained in 202 normal knees (101 pairs). The data showed that although essentially no difference existed between right and left sides, large variations existed in the ratios from one individual to another (range, 0.75-1.46). Thus, the diagnosis of developmental patella infera requires comparison of patellar height ratios in the same knee or between knees in the same individual. A decrease in the vertical-height ratio of 11%-15%, depending on the method used, indicates developmental patella infera.

The Maquet Procedure of Patellofemoral Arthrosis: A 10 Year Study Anthony A. Schepsis, MD, Robert E. Leach, MD, and Gerald Katz, MD—Boston, Massachusetts

The Maquet Procedure of Patellofemoral Arthrosis: A 10 Year Study Anthony A. Schepsis, MD, Robert E. Leach, MD, and Gerald Katz, MD—Boston, Massachusetts

Degenerative Joint Disease in Ballet Dancers

Forty-four retired dancers were studied with regard to degenerative joint disease in the lower limbs. Six cases of coxarthrosis were found, significantly more than expected in the general population. In addition, there were four cases of tibio-femoral arthrosis, six of knee osteophytosis, four of patellofemoral arthrosis, three of chondrocalcinosis, and one of bilateral ankle arthrosis. More than one-half of the dancers had arthrosis in the metatarsophalangeal joints.

Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera.

Infrapatellar Contracture Syndrome (IPCS) is an infrequently recognized cause of posttraumatic knee morbidity. Unique to this group of patients is the combination of restricted knee extension and flexion associated with patella entrapment. IPCS can occur primarily as an exaggerated pathologic fibrous hyperplasia of the anterior soft tissues of the knee beyond that associated with normal healing. It can also occur secondarily to prolonged immobility and lack of extension associated with knee surgery, particularly intraarticular ACL reconstruction. IPCS follows a predictable natural history which is divided into three stages. Symptoms, diagnostic findings, and recommended treatment are determined by the stage at presentation. Once beyond its early presentation, IPCS is best treated by an anterior intraarticular and extraarticular capsular debridement and release, followed by extensive rehabilitation. The authors review 28 consecutive cases of IPCS. At followup 3 months to 4 years postoperation, the patients had averaged 2.3 additional surgical procedures following their index procedure or injury. The average increase in extension at followup was 12 degrees with the average increase flexion 35 degrees. Eighty percent of patients demonstrated signs and symptoms consistent with patellofemoral arthrosis; 16% of the patients demonstrated patella infera. The authors conclude that prevention or early detection and aggressive treatment are the only ways of avoiding complication in these problem cases.

左右で治療法の異なった両側膝蓋大腿関節症の４例

Mono-compartment type of the patello-femoral arthrosis affected both sides were treated differently for four cases. All cases were females with age range 50-72 (mean 62) years and the articular cartilage of the lateral facet of their patellae showed widely defected. They had never complained of patello-femoral arthralgia before. Cases 1 and 4 were treated by spongialization with release of lateral retinaculum (operation A) for one side and by anteromedial transfer of tibial tuberosity with operation A (operation B) for another side, and cases 2 and 3 treated by operation B and by conservative methods. Fallow-up ranged 11 months to 3 years and 7 months, with a mean of 2 years and 2 months. Pain was improved for 8 affected patello-femoral joints, without distinction of the treatment. In comparison between both sides for cases 1 and 4, operation A was satisfied more than operation B for case 4 and vice versa for case 1. Post-operative radiograph showed the centralization of the patella with operation B, but not with operation A. A comparison between conservative treatment and operation B for cases 2 and 3 was difficult, because the sides treated conservatively had moderate pain even before the treatment. Interestingly, one side treated conservatively in case 2 showed no pain at all, while a radiograph still showed complete bony contact of the lateral facet of the patello-femoral joint, which makes the treatment of the patello-femoral arthrosis more difficult and complicated.

Recurrent dislocation of the patella treated by the modified Roux-Goldthwait procedure. A prospective study of forty-seven knees.

We studied the results in forty-seven knees in thirty-seven patients - ten male and twenty-seven female - who had recurrent dislocation of the patella and were treated by a modified Roux-Goldthwait procedure (lateral retinacular release, medial transfer of the lateral patellar tendon without advancement, plication of the medial retinaculum, and advancement of the vastus medialis). Ten of the female patients had bilateral dislocation. The results were analyzed after follow-ups ranging from 3.0 to 16.3 years (average, 5.8 years). The study confirmed that a tangential radiograph of the patellofemoral joint, made with the knee in 20 degrees of flexion, is reliable in determining patellar displacement. The results were excellent in twelve knees, good in thirty-one, fair in one, and poor in three. The fair and poor ratings were due to pain caused by severe chondromalacia patellae. The patient with a fair result had had recurrent dislocations after the Roux-Goldthwait procedure due to a very lax synovial and capsular sac. Reoperation with tightening of the sac medially and laterally eliminated hypermobility of the patella in this patient and established straight patellar tracking. There was one serious complication, a large subcutaneous hematoma with necrosis of a skin flap. The patients with mild chondromalacia improved and showed no progressive patellofemoral arthritis after simple realignment, while those with severe chondromalacia were not improved by shaving, drilling, and realignment. Preliminary results indicated that a modified Maquet procedure, in addition to realignment, may be indicated for patients with severe chondromalacia. This study demonstrated that the modified Roux-Goldthwait procedure, without advancement of the tibial attachment of the patellar ligament, can stabilize the patella without increasing patellofemoral compression. The procedure does not relieve the symptoms of severe chondromalacia of the patella but realignment is the first step in treatment of any form of patellofemoral arthrosis.

Scientific Basis of Extensor Mechanism Disorders

The authors discuss the pathomechanics of abnormal patellar tracking and excessive patellofemoral contact force that results in patellofemoral pain, chondromalacia, and patellofemoral arthrosis. An understanding of the pathomechanics implies a rational approach to treatment that includes methods to correct the tracking problem and reduce the load on the patellofemoral joint.

Open Wedge High Tibial Osteotomy for Gonarthrosis A Follow-up Study

A follow-up study of open wedge high tibial osteotomy was reported.23 knees in 18 patients were evaluated clinically and radiologically with an average period of 5 years and 4 months after the operation. More than 60% of them were good in result. Factors contributing to the poor result were analysed and advantages and disadvantages were discussed.Highly progressed arthrosis and patello-femoral arthrosis were the two factors producing the poor results. Under-correction of varus deformity also caused poor results.In this method, delayed union and postoperative recurrence of varus deformity were the main complications which were considered to occur after inadequate bone graft.

しつがい・大たい関節症の治療

Clinical pictures of patello-femoral arthrosis in elderly patients were described. Our operative procedure gave excellent results.

Biomechanics of the Patellofemoral Joint

The patellofemoral joint contains 2 complex mechanisms for ameliorating forces transmitted across it, namely increasing extensor lever arm-r in the important range of flexion 30 degrees-70 degrees and increasing contact area with increasing flexion. In this range the patella bears sole responsibility for transmitting resultant flexion of quadriceps force to the femur. Here lies the thickest cartilage in the body and perhaps not surprisingly, the most frequent site of cartilage degeneration. The Q-angle and valgus vector explain the predominance of the pathologic lesions on the lateral side of the joint as well as the associated dislocations, subluxations, lateral pressure syndromes, and patellofemoral arthrosis. Extension exercises against resistance produce non-physiologic loading of patellar articular cartilage. Even relatively small loads which are commonly used in physical therapy departments produce pressures far in excess of normal activities, such as stair climbing or squatting. Patients who are placed on such exercise programs are often made worse and develop symptoms which they did not have before. Straight leg raising with weights, on the other hand, maximally stresses the quadriceps muscle without any patellofemoral compression since the patella is out of contact, proximal to the trochlea.

Prosthetic Resurfacing of the Patella

Accumulated data from many sources seem to indicate that prosthetic resurfacing of the patella may be an acceptable alternative to patellectomy in the treatment of chondromalacia patellae or patellofemoral arthrosis. A patellar prosthesis which is made of cobalt-chromium alloy is attached to a remnant of the original patella by means of the acrylic cement, polymethyl methacrylate. An analysis fo the results of the use of this prosthesis in 14 knees of 13 patients reveals excellent or good results in 13 cases and one poor result. The longest follow-up period was 2 years and 9 months and the shortest was 6 weeks. Based on current experience and the experience of others, prosthetic resurfacing of the patella may give the patient some years of pain-free patellofemoral function. This is especially true in patients with poor quadriceps reserve in whom the lever-arm distance of the extensor torque should be maiwtained. Until the ideal resurfacing material is developed, the use of presently available patellar prostheses with or without femoral prosthetic components, is recommended for further investigation.

Experience of Ventralisation of Tibial Tuberosity (Maquet-Bandi's ope.) for Patello-Femoral Arthrosis

Seven patients of chondropathia patellae and patello-femoral arthrosis were operated by ventralisation of tibial tuberosity during 1974 to 1976. Their average length of follow-up was 1.8 years and the maximum was 3 years after operation.All knees of these patients were characterized by either malalignment (patella subluxation, patella alta) or a history of a blow the knee cap.In arthroscopic examination, cartilagnous surface of the patella showed degenerative changes of various forms.This operation gave satisfactory results in all cases with regardless of age, the severity of preoperative symptoms and x-ray findings.It is supposed that the indication of this operation could include not only early stage of patello-femoral arthrosis but also severe stage.