Surgical correction of medial subluxation of the patella.

We evaluated the results of a surgical procedure to correct medial subluxation of the patella in 63 patients (65 knees), most of whom had undergone a lateral retinacular release. We performed a direct repair or a reconstruction of the lateral patellotibial ligament using locally available tissue such as strips of iliotibial band or patellar tendon. Followup averaged 53.7 months (range, 24 to 99). Outcome was based on the examiner's inability to clinically reproduce the patient's painful medial subluxation and on the patient's general impression of his or her improved functional status. Forty-four patients (68%) reported improvement in their functional levels and 49 (75%) reported that they were subjectively improved by the procedure. Overall, 50 patients (80%) had a rating of good or excellent. Six knees required a second surgical reconstruction because of failure to improve or because of a reinjury. Analysis of overall clinical outcome revealed no significant relationships based on the patient's age at the time of the initial procedure, sex, or length of followup (P > 0.10). Reconstitution of the lateral patellotibial ligament effectively corrected medial subluxation of the patella and long-term results of this salvage procedure were satisfactory.

Complications of extensor mechanism surgery for patellar malalignment.

This review focuses on the complications of extensor mechanism surgery for symptomatic patellar malalignment and ways to avoid those complications. We combined a review of new and referred patients who had complications resulting from extensor mechanism surgery with a review of selected literature specifically addressing similar complications. By studying the pathologic anatomy at the time of arthrotomy, it was possible in many cases to determine the causes of adverse outcomes with this type of surgery. The complications of extensor mechanism surgery can be avoided by performing a thorough preoperative evaluation, determining each component of the malalignment, tailoring the procedure to correct each patient's unique pathomechanics, and respecting the functional anatomy of the extensor mechanism.

Surgical treatment of diffuse pigmented villonodular synovitis of the knee.

Twenty-five cases of diffuse pigmented villonodular synovitis of the knee in 23 patients were reviewed to determine the results of surgical treatment. All the cases met strict histologic criteria for diagnosis. Long-term clinical follow-up data (average, 58 months) were available for all patients. One case for a patient who was treated by marginal excision recurred within one year. All other cases (initial and recurrent) were treated by total synovectomy, preserving the functional integrity of the knee. Proximal extensor realignments were performed in patients in which chronic distention had caused a redundancy of retinacular tissues. Adhesions, an early complication in eight patients, responded well to closed manipulation and did not adversely affect long-term functional outcome. The outcome was excellent in seven and good in 16 the patients. Two of the patients have had recurrences but have not had another operation. Using this technique, the recurrence rate (8%) and morbidity are significantly lower than those reported previously.

Diagnostic features of diffuse pigmented villonodular synovitis of the knee.

Twenty-five cases of diffuse pigmented villonodular synovitis of the knee in 23 patients were reviewed to identify characteristic clinical presentations and histologic findings. All cases met strict histologic criteria for diagnosis. Clinical presentation consisted of insidious and progressive symptoms of significant joint swelling with discomfort, but not isolated pain. On physical examination, a suprapatellar pouch that was markedly distended by either effusion, synovial masses, or both, and a slight flexion posture were the most consistent findings. Aspiration to detect a bloody effusion was unreliable as a diagnostic tool. Pigmentation was absent in 16% of the gross specimens. Histologically, iron deposition was present in all cases and to a moderate or marked degree in most. Fibrosis, hyalinization, and chronic inflammatory changes were present in most, but to a lesser degree. No patient had gross, histologic, or treatment follow-up findings consistent with neoplasia. Attempts to predict clinical outcome based on histologic findings were unrewarding.

Case presentation: painless arm swelling in a high school football player.

Paget-Schroetter syndrome, more commonly called "effort thrombosis," has been well documented in the literature but is considered an uncommon cause of morbidity in the athletic population. We describe a case of axillary-subclavian vein thrombosis ("effort thrombosis") that presented as painless arm swelling in a high school football player. This case reviews the presentation, diagnosis, and management of this difficult problem in a young athlete.

Accuracy of clinical isometry and preload testing during anterior cruciate ligament reconstruction.

To determine the effect of suture elongation on the accuracy of tension isometers, an anatomic specimen was used to measure peak loads on suture materials placed in extreme nonisometric positions. Accuracy and reproducibility were determined for three tension isometers, and the influence of suture elongation was determined for one of them. In one device, reproducible readings ranged from -12.3% to + 23.6% of mean static loads recorded by hydraulic testing equipment; average error approached 39.1%. Values tended to be overestimated if readings ranged as high as 32.5% over specific excursion ranges. Selected suture materials were subjected to these loads, using hydraulic testing equipment. Stainless steel exhibited extremely low levels of elongation but only at large diameters. Ethibond had similar low levels of elongation but only at large diameters. Monofilament nylon exhibited significant elongation that could cause erroneous readings and nonisometric placement. The measurement tolerances of a selected tension isometer should be considered by the surgeon performing anterior cruciate ligament (ACL) substitution. Several readings, both loading and unloading, can be used to determine preload and isometry. Material properties of the selected suture and the accuracy of the tension isometer should be considered when interpreting readings from isometric positioners. This brings into question the ability of currently available tension isometers to deliver readings within prescribed tolerances for either isometry of preload testing.

Analysis of subjective knee complaints using visual analog scales.

A questionnaire using a system of visual analog scales was developed for analyzing subjective knee complaints. This system was tested on 117 consecutive patients who had undergone knee surgery and 65 patients at their initial office evaluation of a knee disorder. The validity of and patient affinity for this type of questionnaire was compared with that of three other established subjective evaluation methods. The visual analog scale system was shown to be valid and comparable to other methods while offering several advantages. It brought greater sensitivity and greater statistical power to data collection and analysis by allowing a broader range of responses than did traditional categorical responses. It removed bias that was introduced by examiner questioning, and it allowed graphic temporal comparisons. Most importantly, patient affinity was higher for this type of subjective evaluation than for other methods.

Roentgenographic findings in pigmented villonodular synovitis of the knee.

Twenty-nine cases of pigmented villonodular synovitis (PVS) of the knee in 27 patients were reviewed to determine characteristic roentgenographic findings. All cases met strict histologic criteria for diagnosis. Four cases were localized PVS (LPVS), and 25 cases were diffuse PVS (DPVS). Roentgenographic findings were largely in the soft tissues. Cystic invasion of bone or degenerative changes were rare, although present in some cases. When present in DPVS, these changes were most pronounced in the patellofemoral articular surface. In the cases of DPVS, large posterior tumefactions did not correlate with extraarticular extension. Clinical behavior of PVS was governed more by anatomic site and form of disease than by the severity of histologic or roentgenographic findings.

Pigmented villonodular synovitis of the shoulder.

No characteristic clinical presentation of pigmented villonodular synovitis of the shoulder can yet be determined. Symptoms of discomfort and stiffness may appear insidiously or, in some cases, pigmented villonodular synovitis may be found incidentally during surgery for unrelated problems. Cystic and degenerative changes are more likely to occur in the shoulder than in joints with large synovial recesses such as the knee. Histologic findings parallel those in other joints. Optimal treatment appears to be early marginal excision for the localized form or total synovectomy for the diffuse form. The incidental finding of pigmented villonodular synovitis should not influence the decision to proceed with a preplanned reconstructive procedure. No experience with arthroscopic treatment or radiation therapy for diffuse pigmented villonodular synovitis of the shoulder has been reported.

Diagnosis of anterior knee pain.

A methodical approach to the evaluation of patients with anterior knee pain is extremely helpful. By exploring salient points from the patient's symptoms and history and adding important data from a comprehensive physical examination, the pieces of the puzzle can be fitted together and an accurate diagnosis can be made. This will allow the formulation of a specific plan of rehabilitation that is designed with a knowledge of patellofemoral biomechanics and that will expedite the recovery process and facilitate a return to full function.

The effect of the CAT-CAM above-knee prosthesis on functional rehabilitation.

Five, rehabilitated, unilateral above-knee amputees (average age, 34.4 years) using quadrilateral sockets were converted to Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM) sockets to determine the effect on ambulatory function. Patients were evaluated before and after conversion for subjective acceptance, gait deviations, relative femoral shaft inclination, coronal-plane hip abduction torque, and ambulatory metabolic demands. The CAT-CAM socket was subjectively rated superior by four patients. Most gait deviations improved or disappeared. Femoral shaft inclination angles improved an average of 6.5 degrees toward adduction by roentgenographic measurements in four patients. Film records suggest that the compensatory lateral trunk lean, seen in patients with quadrilateral sockets, diminished after conversion. These four patients increased their customary gait velocities, and all showed a reduction in the quantity of oxygen consumed per meter traveled by up to 50%.

Initial antibiotic therapy for alligator bites: characterization of the oral flora of Alligator mississippiensis.

An open thumb fracture resulting from an alligator bite became infected with Aeromonas hydrophila, Enterobacter agglomerans, and Citrobacter diversus. The patient was treated by surgical debridement and antibiotic therapy. We obtained cultures from the mouth of ten alligators to characterize their oral flora. Initial empiric therapy after alligator bites should be directed at gram-negative species, in particular, Aeromonas hydrophila and anaerobic species including Clostridium. Of the numerous fungi that were isolated, none has been reported to result in wound infection after alligator bites.

Isolated chondral fractures of the knee.

Eighteen patients with isolated chondral fractures of the knee were reviewed to reevaluate the clinical signs and symptoms. No other conditions had been present to account for the symptoms. Most of the patients had significant injuries often involving a flexed knee. All patients had had symptoms and physical findings strongly suggestive of meniscal abnormality. Roentgenographic examinations were noncontributory. The lesions occurred in four distinct patterns. All were full thickness. Many of the lesions occurred on the posterior aspect of a femoral condyle, a location where they could be easily overlooked if the condyle were not examined with the knee in extreme flexion. Abutment of the tibial spine against the medial femoral condyle may be one cause of these injuries. The incidence of isolated chondral fractures was found to be higher than previously reported. A negative arthroscopic meniscal examination in a patient with symptoms and physical findings suggestive of meniscal abnormality should alert the physician to the possibility of an isolated chondral fracture.

A chronically dislocating prosthetic patella. A case report.

A 63-year-old white woman was evaluated for a chronically dislocating right patella 6 months following total knee arthroplasty. At the time of our initial evaluation, her knee would not extend beyond 35 degrees and her patella was dislocated and irreducible. At arthrotomy, when the patella was everted, the patellar component was oriented with the facet ridge rotated 90 degrees to the trochlear groove of the femoral component. The patellar template guide indicated that the fixation pegs had been drilled properly, and thus, the patellar component had been assembled improperly during manufacturing. After dome-type patellar prosthesis replacement and proximal and distal extensor realignments were performed, 2 months post-revision the patient had a range of motion from 5 degrees to 95 degrees and ambulated with no patellar instability or pain.

Tibiofibular synostosis: an unusual cause of shin splint-like pain.

Tibiofibular synostosis may be an underlying cause of tibial pain with activity or ankle pain of uncertain origin. The diagnosis may be suspected when symptoms begin and progress months after an injury, when symptoms occur with vigorous activity, and when symptoms are most pronounced during midstance and preswing phases of the gait cycle. Confirmation of the diagnosis is easily made through radiographic examination, which should include the entire leg. Bone scan may show increased tracer uptake. Interference with normal dynamic function of the fibula subjects the synostosis to repetitive stress and ultimate fatigue fracture with resultant pain. Conservative treatment is recommended initially. Surgical excision should be reserved for the athletically active patient whose symptoms are gradually progressing and disabling, and whose synostosis has taken on the appearance of mature cortical bone on radiographs. The principles of tumor biopsy should be adhered to, lest the diagnosis be in error. Finally, meticulous hemostasis and use of bone wax may lessen the possibility of recurrence.

Functional ambulation in myelodysplasia: the effect of orthotic selection on physical and physiologic performance.

The metabolic demands of ambulation in a reciprocation gait orthosis (RGO) were compared with those in conventional bracing (hip-knee-ankle-foot orthosis) and wheelchair use in eight myelodysplastic children. Heart rate was significantly increased during swing-through gait compared with that during wheelchair use (p less than 0.01). Oxygen consumption studies showed a significant increase in swing-through gait over that in wheelchair use. These values for RGO use approximated wheelchair use. These results suggest a more favorable prognosis for long-term functional ambulation in higher-level myelodysplastic patients if they are fitted with an RGO.