Diffusely increased bone scintigraphic uptake in patellofemoral pain syndrome.

OBJECTIVES: Painful disorders of the patellofemoral joint are one of the most frequent complaints in orthopaedic and sports medicine. The aims of this study were to determine whether bone scintigrams of patients suffering from patellofemoral pain syndrome (PFPS) show diffuse uptake and in what bony compartment of the knee uptake, if any, was localised. METHODS: Fifty eight patients with chronic PFPS were examined. All patients underwent a detailed clinical history and a thorough physical examination of the knee. Anterior and lateral static images of both knees were made using a gamma camera 3 h after injection of 550 MBq of (99m)Tc-HMDP. Two experienced radiologists visually evaluated the scans blindly and separately. As 51 patients had bilateral pain, 109 painful knees are included in the results. RESULTS: Diffuse uptake on bone scintigrams was found in 48 knees in 30 of the patients. In 33 knees the uptake was localised to only one bone compartment, in 10 knees diffuse uptake was found in two of the bones forming the knee joint, and in six knees all three bone compartments (the distal femur, the patella, and the proximal tibia) exhibited diffuse uptake. CONCLUSIONS: Scintigrams of approximately half of the patients with PFPS will show diffuse uptake in one or more of the bony compartments of the knee joint and radioactive tracer accumulation will occur as often in the proximal tibia as in the patella.

Roentgenographic assessment of the hip-knee-ankle axis in medial gonarthrosis. A study of reproducibility.

A preoperative reliable recording of the knee alignment is necessary to calculate the correct wedge at high tibial osteotomy for medial gonarthrosis. To determine the reproducibility of the hip-knee-ankle angle (HKA), a preoperative, whole lower limb roentgenogram was obtained twice in eight patients, and each roentgenogram was judged by two radiologists. Assessment of the HKA had a variability of at most 2 degrees, which is highly significant for a reliable calculation of the wedge at tibial osteotomy.

Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study.

High tibial osteotomy for medial gonarthrosis was performed in 28 patients (28 knees). At the time of surgery, arthroscopy was also performed and a cartilage-bone biopsy was obtained. Postoperatively, 15 patients were randomized to a cylinder plaster cast, whereas 13 patients had a hinged cast brace for early knee mobilization. At follow-up examination, two years after surgery, 16 patients accepted an arthroscopic examination with a cartilage-bone biopsy. In overcorrected knees, cartilage regeneration was found in eight of 14 patients on the medial tibial condyle and in nine of 14 on the medial femoral condyle. The main repair feature was proliferation of fibrocartilage, which covered bone and areas of fibrillated cartilage and filled vertical clefts in hyaline cartilage. The hyaline cartilage showed an increased cellularity with numerous nests of proliferating chondrocytes. No correlation was found between clinical outcome and the degree of cartilage regeneration as observed by arthroscopy, biopsy, or roentgenography. Knees with a brace postoperatively had better knee flexion two years after surgery. No difference in cartilage regeneration was recorded between knees with a plaster cast or a cast brace postoperatively.

Prognosis for patients with medial gonarthrosis. A 16-year follow-up study of 189 knees.

All 189 knees (157 patients) that had had primary medial compartment arthrosis in 1972 were followed until 1988. After 14 years, tibial osteotomy had been performed in 85 knees and arthroplasty in 33 knees. No major surgery had been performed in 71 knees; of these 71 knees, 31 patients (40 knees) had died. Of the remaining 23 patients (31 knees), the majority had an unsatisfactory knee and managed only on a low activity level. In 20 of 24 knees, progress of the arthrosis was recorded roentgenographically. Because natural course of medial gonarthrosis has a poor prognosis, the majority of patients suffering from this condition will eventually have major knee surgery.

Proteoglycan epitope in synovial fluid in gonarthrosis. 28 cases of tibial osteotomy studied prospectively for 2 years.

High tibial osteotomy was performed for medial gonarthrosis in 28 patients. Preoperatively, and at 3, 12, and 24 months after surgery, clinical and radiographic examinations were made, and joint-fluid samples were aspirated. Arthroscopy was performed preoperatively and at 24 months. Immunoassay of proteoglycan epitope in joint fluid showed an increase in concentration at all times as compared with a reference population with normal knee joints. An increase in both the concentration and the total amount of proteoglycan epitope in joint fluid was noted at 3 months postoperatively with a return to preoperative values at later times. Regrowth of fibrocartilage did not correlate with proteoglycan epitope data.

Ten-year results of tibial osteotomy for medial gonarthrosis. The influence of overcorrection.

The results in relation to the correction achieved 1 year after surgery of a series of tibial osteotomies in 50 patients (52 knees) are presented with a total observation time of 10 years. Mean age at the time of osteotomy was 56 years. Overcorrected knees had a significantly better result after 10 years. Progress of gonarthrosis occurred in 6/34 overcorrected knees compared with 3/4 in the normo- and undercorrected group. One out of 34 overcorrected knees recurred in varus. Five knees were revised by knee arthroplasty or reosteotomy one of which was overcorrected.

Revision after osteotomy for gonarthrosis. A 10-19-year follow-up of 314 cases.

During a 10-year period, 314 tibial osteotomies were performed for medial gonarthrosis. At follow-up after 10-19 years, 62 knees had been revised by arthroplasty (52 cases) or reosteotomy (10 cases). The revision rate was 54/170 in undercorrected knees and 8/144 in knees with normalization or overcorrection of the hip-knee-ankle angle. Our results confirm that tibial osteotomy for gonarthrosis requires proper indications and precise surgery. Perhaps, given another 10 years, our osteotomies will have outlived contemporary arthroplasties.

Early knee mobilization after osteotomy for gonarthrosis.

In a prospective study, 32 knees in 32 patients were randomized to either a cylinder plaster cast (17 knees) or hinged cast-brace (15 knees) after high tibial osteotomy for medial gonarthrosis. At 6 weeks, 3 months, and still 1 year after surgery, the range of motion was better in the cast-brace group. There was no difference in the other clinical results at 3 months and at 1 year after surgery, nor in changes of osseous correction or in the final knee alignment. All the patients in the cast-brace group were satisfied with early motion.

Function after tibial osteotomy for medial gonarthrosis below aged 50 years.

Twenty-seven patients (28 knees), with a median age of 42 (27-50) years treated with a high tibial osteotomy for early medial gonarthrosis (Ahlbäck's Stage I) were examined after 11 (7-18) years. Twenty-four were men; 18 knees had had previous meniscus and ligament lesions. At follow-up, 22 knees were satisfactory and 9 patients managed high-activity sports or heavy work. In 25/28 knees, the arthrotic process had not progressed radiographically.

A guide instrument for high tibial osteotomy.

Fifty-two patients (52 knees) with medial gonarthrosis were subjected to high tibial osteotomy using the Tjörnstrand guide instrument. The intended wedge was calculated from a whole lower limb radiograph. The correction aimed at was an overcorrection of 4 degrees in valgus of the hip-knee-ankle angle. All but 1 case were corrected to +/- 3 degrees of the intended angle. All but two cases healed within +/- 3 degrees of the achieved surgical correction, i.e., a substantial improvement compared with our previous freehand technique where one fifth were outside this interval. We conclude that in knee surgery a guide is as important for osteotomies as for arthroplasties.

Lateral meniscal lesions in patients with clinically suspected medial lesions.

Double-contrast arthrography and arthroscopy were performed in a prospective study on 46 consecutive patients clinically suspected of having a medial meniscal tear only. At arthrography, 38 torn medial menisci were found; four of them were, however, false-positive and another false-negative as compared with arthroscopic examination. Moreover, seven unsuspected lateral meniscal tears were diagnosed at both arthrography and arthroscopy. The diagnostic accuracy of the double-contrast arthrography was well above the clinical accuracy, and we conclude that arthrography is a reliable method for diagnosing both medial and lateral tears.

Neurovascular injury complicating displaced proximal fractures of the humerus.

Three cases with injury of the axillary artery and brachial plexus complicating a displaced proximal fracture of the humerus are presented. In two patients the arterial injury was not recognized on admission. Vascular repair had to be carried out in all three cases. Two patients showed a persistent neurological deficit. In two of the cases, the arterial injury may have been caused by an attempt at closed reduction of the fracture. The possibility of axillary arterial injury should be considered in proximal fractures of the humerus with severe medial displacement of the shaft of the humerus.