Medial Patellofemoral Ligament Injury. Location-Based Rate of Recurrent Patellar Dislocation After Non-Operative Treatment.

OBJECTIVES: The 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 imagine. 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. METHODS: In total, 64 eligible patients with a first-time traumatic patellar dislocation were recruited to the trial. The diagnosis was confirmed within three weeks with 3 Tesla magnetic resonance imaging (MRI). 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. RESULTS: Out 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 statistically significant effect on 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, range of motion was more restricted in patients with MPFL injury at the femoral insertion (93.4° vs. 108.0° for injury at the midsubtance area and 107.7° at the patellar insertion). CONCLUSION: The location of MPFL injury did not have statistically significant effect on timing or rate of re-dislocations. The MPFL injury at the femoral insertion predicts decreased ROM of the knee and increased quadriceps muscle atrophy during the first three months after sustaining injury. LEVEL OF EVIDENCE: Level III.

No difference was found between double-bundle and single-bundle anterior cruciate ligament reconstructions in terms of osteoarthritis at 15-year follow-up.

PURPOSE: The purpose of the study was to determine whether the grade of osteoarthritis (OA) is higher with single-bundle (SB) or double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. The hypothesis was that there will be no difference in the grade of OA between the techniques. METHODS: This study was a randomised controlled trial (RCT) with a follow-up period of 15 years. Patients were randomly assigned to either the SB group (n = 78) or the DB group (n = 75). Surgical techniques were anatomic, and the rehabilitation protocol was standardised. Evaluation included Kellgren-Lawrence (KL) difference and absolute OA results. OA was defined as a KL grade of at least 2. RESULTS: At 15-year follow-up, information was available on 101 patients (66%), of whom 56 (37%) were accepted in the final statistical analysis. No difference was found between the SB and DB techniques in terms of KL difference or absolute OA results. Significantly less OA was found in the contralateral knee (21%) than in the reconstructed knee (59%) (p < 0.001). Patients with meniscal tears who underwent partial meniscal resection during ACL reconstruction had a significantly higher rate of OA changes (82%) compared with patients with isolated ACL tears (33%) (p < 0.001). A longer delay between initial injury and surgery did not appear to affect the severity of the KL classification. CONCLUSION: At 15-year follow-up, no difference was found between the DB and SB techniques in terms of OA. LEVEL OF EVIDENCE: Level I.

Open Reduction Internal Fixation vs Primary Arthrodesis for Displaced Lisfranc Injuries: A Multicenter Randomized Controlled Trial.

BACKGROUND: There is no consensus whether the primary surgical method should be open reduction and internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries. The aim of our randomized controlled trial was to compare ORIF and PA for displaced Lisfranc injuries. METHODS: This study was a national multicenter randomized controlled trial. Altogether 43 displaced Lisfranc injuries were enrolled in this trial. The primary outcome measure was Visual Analogue Scale Foot and Ankle (VAS-FA) at a 24-months follow-up. The secondary outcome measures were VAS-FA pain, function, and other complaints subscales and the American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6, 12, and 24 months. We were unable to reach the planned sample size of 60 patients; thus, the study remains underpowered. RESULTS: The mean VAS-FA Overall score in the ORIF group was 86.5 (95% CI 77.9, 95.1) and 80.1 (95% CI 72.0, 88.1) in the PA group at the 24-month follow-up. We did not find eligible evidence of a difference in VAS-FA Overall scores (mean between-group difference 6.5 [95% CI -5.3, 18.2], Cohen d = 0.100). CONCLUSION: We did not find evidence of a difference in VAS-FA between ORIF and PA in patients with displaced Lisfranc injuries, and thus both are viable options for the initial surgical method. The trial is underpowered; however, the data may be included in a meta-analysis of similarly designed randomized controlled trials.ClinicalTrials.gov identifier: NCT02953067 24 October 2016.

Double-bundle anterior cruciate ligament reconstruction resulted in better International Knee Documentation Committee objective grading at fifteen year follow-up compared to single-bundle reconstruction.

PURPOSE: The aim of this prospective randomized study was to evaluate whether the use of the anatomic double-bundle (DB) method for anterior cruciate ligament (ACL) reconstruction results in better clinical outcomes and a lower incidence of graft failure compared with the anatomic single-bundle (SB) method. The hypothesis was that DB ACL reconstruction would result in a lower incidence of graft failure. METHODS: Patients were randomly assigned to either the SB group (n = 78) or the DB group (n = 75). Evaluation included clinical testing, subjective assessments, functional testing, and International Knee Documentation Committee (IKDC) objective grading. Surgical techniques were anatomic, and the rehabilitation protocol was standardized. RESULTS: At 15-year follow-up, information was available on 100 patients (65%), of whom 55 (36%) were accepted in the final statistical analysis. There were almost three times as many graft failures in the SB group, but the result wasn´t statistically significant. Subjective assessments, knee stability (KT -1000 and pivot shift), range of motion (ROM), and functional one leg hop test showed no statistically significant differences between the groups. However, DB ACL reconstruction resulted in better International Knee Documentation Committee objective grading (P < 0.001). CONCLUSION: At the 15-year follow-up, double-bundle surgery resulted in significantly better International Knee Documentation Committee objective grading compared to single-bundle surgery.

A Randomized Controlled Trial Comparing a Patella-Stabilizing, Motion-Restricting Knee Brace Versus a Neoprene Nonhinged Knee Brace After a First-Time Traumatic Patellar Dislocation.

BACKGROUND: A traumatic lateral patellar dislocation is a common injury in adolescents and young adults. The majority of first-time dislocations can be treated nonoperatively. Various types of knee braces are used for nonoperative treatment, but evidence on the most preferable bracing method is lacking. PURPOSE: To evaluate the efficacy of a patella-stabilizing, motion-restricting knee brace versus a neoprene nonhinged knee brace for the treatment of a first-time traumatic patellar dislocation at 3 years of follow-up. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 101 skeletally mature patients with a first-time traumatic patellar dislocation were enrolled in the study. After exclusion criteria were applied, 79 patients with a first-time traumatic patellar dislocation were randomized and allocated into 2 study groups: group A, with a patella-stabilizing, motion-restricting knee brace (hinged to allow knee range of motion [ROM] of 0°-30°) and group B, with a neoprene nonhinged knee brace (not restricting any knee motion). Both groups received similar physical therapy instructions and were advised to use the brace continuously for 4 weeks. Overall, 64 patients completed the trial. RESULTS: The redislocation rate in group A was 34.4% (11/32) and in group B it was 37.5% (12/32) (risk difference, -3.1% [95% CI, -26.6% to 20.3%]; P = .794). Patients in group A had less knee ROM than those in group B at 4 weeks (90° vs 115°, respectively; P < .001) and 3 months (125° vs 133°, respectively; P = .028). Patients in group A had more quadriceps muscle atrophy than patients in group B at 4 weeks (24/32 vs 16/32, respectively; P = .048) and 3 months. At 6 months, patients in group B reported better functional outcomes than patients in group A (Kujala score mean difference, 4.6; P = .012), although no clinically relevant difference was found at 3 years. CONCLUSION: The use of a patella-stabilizing, motion-restricting knee brace for 4 weeks after a first-time traumatic patellar dislocation did not result in a statistically significant reduction in redislocations versus a neoprene nonhinged knee brace, although this trial was underpowered to detect more modest differences. Knee immobilization was associated with quadriceps muscle atrophy, less knee ROM, and worse functional outcomes in the first 6 months after the injury. REGISTRATION: NCT01344915 (ClinicalTrials.gov identifier).

Double bundle ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than single bundle ACL reconstruction.

PURPOSE: The purpose of this meta-analysis is to compare arthroscopic single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstructions in the light of all available randomised controlled trials (RCTs). A meta-analysis of this well-researched topic was performed and subgroup analyses of the medial portal (MP) technique and the transtibial technique (TT) were added as a new idea. The hypothesis was that the DB technique is superior to the SB technique also in subgroup analyses of the MP and TT techniques. METHODS: Instructions of the PRISMA checklist were followed. Systematic literature search from electronic databases, including PubMed, Cochrane library and Scopus was performed to find RCTs that compared the SB and DB techniques. Nine outcomes were used to compare these two techniques. Each study was assessed according to the Cochrane Collaboration's risk of bias tool and three subgroup analyses (minimum 2-years' follow-up, TT technique and MP technique) were performed. RESULTS: A total of 40 studies were included in this meta-analysis. When analysing all the included studies, the DB technique was superior to the SB technique in KT-1000/2000 evaluation (p < 0.01), IKDC subjective evaluation (p < 0.05), Lysholm scores (p = 0.02), pivot shift (p < 0.01) and IKDC objective evaluation (p = 0.02). Similar results were also found in the subgroup analyses of minimum 2-years' follow-up and the TT technique. However, there were no differences between the two techniques in a subgroup analysis of the MP technique. CONCLUSION: Generally, DB ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than SB ACL reconstruction. The subgroup analysis of the MP technique revealed that surgeons can achieve equally as good results with both techniques when femoral tunnels are drilled through the medial portal. LEVEL OF EVIDENCE: II.

Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients.

BACKGROUND: Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries. METHODS: In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. RESULTS: In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery. CONCLUSION: Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies. LEVEL OF EVIDENCE: IV, retrospective case series.

Bioabsorbable vs. titanium screws for first tarsometatarsal joint arthrodesis: An in-vitro study.

BACKGROUND: The TMT-1 joint arthrodesis is a common repair for severe hallux valgus. Two crossing interfragmental screws, usually titanium or steel, and a locking plate or a plate with a compression screw are the most common fixation methods for first TMT joint arthrodesis. The qualities of an ideal fixation material include adequate strength and rigidity, biocompatibility, lack of interference with bone healing, lack of visibility and palpability, and a low risk of surgical removal. We sought to determine whether bioabsorbable cannulated screws would perform as well as titanium screws in anatomical models. METHODS: Identical anatomical TMT-1 arthrodesis was created with a saw by making a straight cut in 30 anatomical models (Sawbone®). The bioabsorbable and titanium screws were placed one at a time in exactly the same location in each model according to careful measurements. All 30 models were analyzed with a material testing machine (MTS Insight 30, Eden Prairie, USA). Each model was oriented 15° to the platform to simulate its position to the ground during mid-stance. RESULTS: In the single-cycle load-to-failure test, the mean yield load was 61.4 N ±â€¯5.7 N (range, 50.1 N-70.3 N) in the bioabsorbable screw group and 81.2 N ±â€¯12 N (range, 61.7 N-113.4 N) in the titanium screw group (P < .001). The respective values for the stiffness of the fixation were 8.1 N/mm ± 0.8 N/mm (range, 6.7 N/mm to 9.1 N/mm) and 9.7 N/mm ±â€¯1.8 N/mm (range, 6.9 N/mm to 12.6 N/mm) for the bioabsorbable and titanium groups (P = .004). The mean maximum failure loads in the bioabsorbable group were 85.1 N ±â€¯8.5 N (range, 67.1 N-97.2 N) and in the titanium group 120.6 N ±â€¯13.2 N (range, 96.7 N-136.7 N), respectively (P < .001). Analysis of the failure models shows bioabsorbable fixation failures caused by bending occur more often than in the titanium group. CONCLUSION: In biomechanical testing, titanium screws were stronger than bioabsorbable screws in the TMT-1 arthrodesis model tested, although bioabsorbable cannulated screws may be an alternative to titanium screws in the fixation Lapidus procedure.

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries.

BACKGROUND: Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. METHODS: One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. RESULTS: Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). CONCLUSIONS: Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. LEVEL OF EVIDENCE: III.

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study.

Background and purpose - Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods - The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results - 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29-32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12-14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation - Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

Incidence of hallux valgus primary surgical treatment. Finnish nationwide data from 1997 to 2014.

BACKGROUND: Many surgical procedures have been described for hallux valgus. Evidence provided by the current literature on the different procedures is, however, poor. The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and to find out whether changes in operation techniques of HV have occurred during the study period. METHODS: The study included all adult patients (≥18 years) who underwent primary HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data were collected by the Finnish National Hospital Discharge Register (NHDR). RESULTS: The total incidence of primary HV operations was 66.7 per 100,000 person-years in 1997 and 41.4 per 100,000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time the incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies. CONCLUSION: This study shows a significant decreasing trend of HV operations in Finland between 1997 and 2014. During the study period, the incidence of MTP I joint arthroplasty decreased, and since 2005 the incidence of MT-1-osteotomies has almost halved. At the same time, the incidence of MTP-1 joint arthrodesis increased by over 1000% and TMT-1 joint arthrodesis by nearly 2000%.

Incidence and Characteristics of Midfoot Injuries.

BACKGROUND:: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging-based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. METHODS:: All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. RESULTS:: During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. CONCLUSIONS:: The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma. LEVEL OF EVIDENCE:: Level III, epidemiologic study.

Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial - study protocol.

BACKGROUND: Lisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries. METHODS: This study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period. DISCUSSION: This publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02953067 24.10.2016.

Epidemiology of calcaneal fractures in Finland.

BACKGROUND: The purpose of this study was to assess the nationwide incidence (per 100,000 person-years) of operative treatment and hospitalization due to calcaneal fractures (CF) in Finland. METHODS: The study was based on the Finnish National Hospital Discharge Register. All patients aged 18-years or older admitted to Finnish hospitals for primary treatment of CF in 1987-2012 were included. RESULTS: During the 26-year study period 5977 patients were hospitalized with main or secondary diagnosis of a CF. The incidence of hospitalization due to CF remained relatively stable: (12.5)/100,000 in men and 3.9/100,000 in women. The men were younger (median 43 years) than the women (median 61 years). CONCLUSIONS: The incidence of the hospitalization due to CF in Finland has remained at steady level during the past 26 years. The incidence of CF is three times higher in men. In 2012 22% of the fractures were operatively treated.

Traumatic Patellar Dislocation and Cartilage Injury: A Follow-up Study of Long-Term Cartilage Deterioration.

BACKGROUND: Patellofemoral cartilage deterioration and osteoarthritis are reported to be associated with recurrent patellar dislocation. However, the association between first-time traumatic patellar dislocation and cartilage deterioration is unknown. PURPOSE: The aim of this study was to assess long-term cartilage deterioration in the patellofemoral and tibiofemoral joint after conservatively treated traumatic lateral patellar dislocation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty patients (mean age, 25 years) who sustained first-time traumatic lateral patellar dislocation with no previous patellofemoral instability symptoms were initially scanned with 1.5-T magnetic resonance imaging (MRI). A follow-up 3-T MRI was conducted, on average, 8 years after first-time lateral patellar dislocation. Subjective instability symptoms and Knee injury and Osteoarthritis Outcome Score were also assessed. RESULTS: In the primary MRI, patellofemoral cartilage injury was seen in 14 of 20 patients (70%). Most (14/15) of the injuries were seen in the patellar cartilage, especially at the medial facet. On the follow-up MRI, patellofemoral cartilage deterioration was visible for all patients. The central patella ( P = .005) seemed especially prone to cartilage deterioration during the follow-up. Half of the patients (10/20) had grade 3-4 cartilage lesions in the patellofemoral joint in the follow-up MRI. In the primary MRI, only 1 patient exhibited tibiofemoral joint cartilage lesions, whereas at the time of follow-up, 10 of 20 patients exhibited tibiofemoral cartilage lesions. The majority of these lesions were considered clinically nonsignificant (International Cartilage Repair Society = 1) and were seen in the lateral compartment (6/10, 60%). Of the 14 patients (36%) with injury to the patellar cartilage, 5 reported subsequent instability of the patellofemoral joint, but this was not associated with more significant cartilage deterioration in the follow-up MRI compared with patients without redislocation. CONCLUSION: While recurrent lateral patellar dislocation is known to lead to degenerative process, a single first-time or infrequently recurring traumatic lateral patellar dislocation also seems to be associated with gradual cartilage deterioration. Traumatic lateral patellar dislocation might initiate gradual degeneration of the cartilage in the patellofemoral joint and can lead to the development of generalized knee osteoarthritis. Instability symptoms of the patellofemoral joint, however, were not related to the severity of the deterioration.

Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome.

PURPOSE: To define medial patellofemoral ligament (MPFL) injury characteristics at the patellar attachment and clinical outcome in patients with primary traumatic patellar dislocation and MPFL avulsion injury at the patella. METHODS: Magnetic resonance imaging (MRI) was used to assess patients with primary (first-time) patellar dislocation and MPFL injury at the medial margin of the patella. Fifty-six patients with patellar attachment MPFL injury were enrolled in the study. Thirteen patients underwent surgical fixation of the avulsed MPFL and patellar medial margin osteochondral fracture, and the remaining patellar MPFL injures were treated nonoperatively. Forty-four patients were evaluated clinically at median four (range 1-10) years after patellar dislocation. The follow-up included evaluation of recurrent patellar instability, subjective symptoms, and functional limitations. RESULTS: Three types of patellar MPFL injuries were found; type P0 with ligamentous disruption at the patellar attachment, type P1 with bony avulsion fracture from the medial margin of the patella, and type P2 with bony avulsion involving articular cartilage from the medial facet of the patella. Of the patellar MPFL avulsion injuries that underwent initial surgical fixation, two patients (2/13) reported an unstable patella at follow-up. Fifty-five per cent (17/31) of patellar MPFL avulsion injuries that were treated nonoperatively had recurrent patellar instability (n.s.). The median Kujala score was 90 for patellar avulsion with surgical fixation and 86 for patellar avulsion without surgical fixation (n.s.). CONCLUSION: Patellar attachment MPFL injury showed three different patterns, classified as types P0, P1, and P2. MRI can be used to assess the injury pattern. Patellar MPFL avulsion injuries do not benefit from acute surgical repair compared with nonsurgical treatment. Type P2 patellar MPFL avulsion includes an osteochondral fracture that may require surgical fixation. LEVEL OF EVIDENCE: Prognostic study, Level III.

Effect of immobilization, off-loading and zoledronic acid on bone mineral density in patients with acute Charcot neuroarthropathy: a prospective randomized trial.

BACKGROUND: Bisphosphonates are commonly used as an adjuvant in the management of acute Charcot neuroarthropathy (CNA), although the clinical efficacy of the treatment is controversial. The aim of the present study is to investigate the effect of immobilization and zoledronic acid on bone mineral density (BMD) changes during the treatment of acute CNA. METHODS: Thirty-five patients with acute midfoot CNA were randomly assigned to treatment with either zolendronic acid or placebo. BMD of the lumbar spine and both hips was measured at baseline and after six months of treatment. RESULTS: Comparison between BMD at presentation and at 6 months demonstrated a significant fall in BMD in the placebo group at the CNA-affected femoral neck (-3.2%, p=0.016) and in the CNA-free hip (-1.2%, p=0.026). Conversely, a significant rise in BMD was observed in the zolendronic acid group at all measured areas of the CNA-free hip. DISCUSSION AND CONCLUSIONS: Immobilization and off-loading does not lead to marked disuse osteoporosis in patients with acute CNA after 6 months of treatment. Treatment with zoledronic acid led to a statistically significant increase in hip BMD compared to placebo.

First-time patellar dislocation: surgery or conservative treatment?

Primary patellar dislocation injures the medial patellofemoral ligament (MPFL), the major soft-tissue stabilizer of the patella, which may lead to recurrent patellar instability. Recurrent patellar dislocation are common and may require surgical intervention. The variation in location of injury of the MPFL and the presence of an osteochondral fracture produces challenges in clinical decision making between nonoperative and operative treatment, including the surgical modality, to repair or reconstruct the MPFL. Current evidence suggests that not all primary dislocations should undergo the same treatment. MPFL reconstruction may theoretically be more reliable than repair, but the optimal time to perform additional bony corrections is not known. A normal or minor dysplastic patellofemoral joint may be suitable for nonoperative treatment, whereas a higher grade of trochlear dysplasia or other significant abnormalities may benefit from surgical treatment. In this paper, we present a treatment algorithm for primary patellar dislocation.

[Ankle ligament injury: diagnosis and functional therapy]. / Nilkan ligamenttivamman diagnostiikka ja funktionaalinen hoito.

Primary treatment of acute ankle ligament injury is almost always conservative. The more severe injury is, the more careful initial treatment, rehabilitation and follow-up is required. If the rupture of ligaments is suspected, the ankle must be supported with an air splint or ankle support. Functional therapy is initiated immediately upon the occurrence of the injury. Independent training by the patient is the cornerstone of functional therapy. Persistence of symptoms or recurrent injuries are often due to inadequate rehabilitation.

The effect of zoledronic acid on the clinical resolution of Charcot neuroarthropathy: a pilot randomized controlled trial.

OBJECTIVE: To investigate the clinical efficacy of zoledronic acid in patients with diabetes and acute Charcot neuroarthropathy. RESEARCH DESIGN AND METHODS: Thirty-nine consecutive patients were randomly assigned to placebo or three intravenous infusions of 4 mg zoledronic acid. The primary outcome was clinical resolution of acute Charcot neuroarthropathy determined by total immobilization time (casting plus orthosis). RESULTS: At baseline, there was no significant difference between the randomly assigned groups with respect to Charcot disease activity or other baseline values. In the zoledronic acid group, the median time for total immobilization was 27 weeks (range 10-62), and in the placebo group it was 20 weeks (20-52) (P=0.02). CONCLUSIONS: Zoledronic acid had no beneficial effect on the clinical resolution of acute Charcot neuroarthropathy in terms of total immobilization time. It is possible that it may prolong the time to clinical resolution of Charcot neuroarthropathy.