The Diagnosis and Initial Treatment of Patellofemoral Disorders.

Our purpose is to provide simple guidelines for the diagnosis and early care of patellofemoral disorders. Any clinician who treats knee problems, including family practitioners, rheumatologists, orthopedic surgeons, or physical therapists, must know how to make the correct diagnosis, or at least a presumptive diagnosis, at the initial visit. This can avoid unneeded and costly tests, ineffective treatment, and even damaging exercises and unnecessary surgery. The diagnosis of patellofemoral disorders is confusing because they can have many causes. That is, the etiology of patellofemoral disorders is multifactorial. To dispel this confusion and simplify the process, we use a clinical classification based on etiology. Within that framework are 7 key abnormalities or factors that can cause both patellofemoral pain and instability: vastus medialis obliquus deficiency, medial patellofemoral ligament laxity, lateral retinaculum tightness, increased quadriceps angle, hip abductor weakness, patella alta, and trochlear dysplasia. At the initial evaluation, the clinician can assess for these abnormalities through history-taking, physical examination, and standard radiography. Any abnormalities identified, along with their severity, can be used to arrive at a diagnosis, or a presumptive diagnosis, and begin early nonoperative treatment. The clinician does not need magnetic resonance imaging at this point, unless a presumptive diagnosis cannot be made or a more complex problem is suggested.

Patellofemoral arthroplasty: 7-year mean follow-up.

Patellofemoral arthroplasty has had renewed interest with the purpose of this study to evaluate its outcomes. Between 2001 and 2006, 43 were performed in 37 patients who had a mean follow-up of 7 years (range, 4-8 years). Patient outcomes were determined using Knee Society objective and function scores, revision rates, and complication rates. The 5-year Kaplan-Meier survivorship was 95%. Knee Society objective scores improved from a mean of 64 points (range, 57-68 points) to 87 points (range, 50-100 points), and functional scores improved from a mean of 48 points (range, 45-50 points) to 82 points (range, 20-100 points). This study shows maintained successful clinical and radiographic results at mean 7-year follow-up for patellofemoral arthroplasty.

Scientific evidence for the use of modern patellofemoral arthroplasty.

Patellofemoral arthroplasty has been utilized as a treatment for isolated patellofemoral arthritis for more than 30 years. However, the use of this procedure remains controversial, as many surgeons prefer to use total knee arthroplasty, even for isolated patellofemoral arthritis. While historically, the results with this procedure have been inconsistent, recent developments in prosthesis design and surgical indications have improved the outcomes of patellofemoral arthroplasty. Potential advantages of patellofemoral arthroplasty include a less invasive approach, less bone resection, less tissue destruction, shorter operative time, less blood loss, shorter rehabilitation, and more normal knee kinematics. However, proper indications and surgical technique are crucial in order to obtain optimal results. Some future modifications have the potential to further improve the outcomes of the procedure, although additional investigations are needed to further explore some of these aspects. This report will describe current knowledge regarding the indications and contraindications for patellofemoral arthroplasty, present the results and complications of this procedure, discuss alternative treatments for patellofemoral disease, and explore future directions for arthroplasty of the patellofemoral compartment.

Patellofemoral arthroplasty: a multi-centre study with minimum 2-year follow-up.

Recently, patellofemoral arthroplasty has attracted increased interest as a salvage treatment for isolated patellofemoral arthritis. However, there are very few reports of the experience with modern generation patellofemoral arthroplasties. This investigation describes a collective experience of four centres reporting on the outcome in patients of the use of one patellofemoral arthroplasty device. There were 70 patients (79 knees) who had failed an extensive non-operative treatment regimen and/or various conventional alternative surgical treatments. At a mean follow-up of three years (range: 2-6 years), there were 66 knees that had Knee Society Scores greater than 80 points (84%). Seventy-one knees (90%) functioned without pain in daily activity and stair climbing. Symptomatic isolated patellofemoral arthritis was successfully treated with a patellofemoral arthroplasty in the short term. We are encouraged by these excellent early results and await longer follow-up.

The female knee: anatomic variations and the female-specific total knee design.

UNLABELLED: The concept and need for a gender-specific or female-specific total knee prosthesis have generated interest and discussion in the orthopaedic community and the general public. This concept relies on the assumption of a need for such a design and the opinion that there are major anatomic differences between male and female knees. Most of the information regarding this subject has been disseminated through print and Internet advertisements, and through direct-to-patient television and magazine promotions. These sources and a recent article in a peer-reviewed journal, which support the need for a female-specific implant design, have proposed three gender-based anatomic differences: (1) an increased Q angle, (2) less prominence of the anterior medial and anterior lateral femoral condyles, and (3) reduced medial-lateral to anterior-posterior femoral condylar aspect ratio. We examined the peer-reviewed literature to determine whether women have had worse results than men after traditional TKAs. We found women have equal or better results than men. In addition, we reviewed the evidence presented to support these three anatomic differences. We conclude the first two proposed differences do not exist, and the third is so small that it likely has no clinical effect. LEVEL OF EVIDENCE: Level IV, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.

Patellofemoral arthroplasty in the treatment of patellofemoral arthritis: rationale and outcomes in younger patients.

Patellofemoral degenerative disease encompasses a spectrum of articular wear from severe chondrosis to advanced arthrosis. The rationale and timing for many operative approaches currently advocated for the relief of symptomatic patellofemoral degeneration can be the subject of intense surgical debate in any one patient. Unfortunately, the limited efficacy of many commonly advocated operative procedures has left a legacy of patellofemoral disability in many younger individuals. While total knee arthroplasty has an established role in the treatment of advanced patellofemoral arthritis in the older patient (age >60 years), the performance of what some have called "a knee joint amputation" in younger patients (age <45 years) remains controversial and less acceptable to patients. The Avon patellofemoral prosthesis is a second-generation knee joint-conserving device that has consistently achieved good to excellent results in both the primary treatment and salvage of patellofemoral degenerative disease in younger patients. In addition, patellofemoral arthroplasty has demonstrated success as a unique functional, tibial-femoral joint-conserving solution in a variety of other patellofemoral extensor mechanism problems.

The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures.

UNLABELLED: Patellofemoral arthroplasty is going through a recent resurgence in interest with various new designs being introduced for general orthopaedic use. With this renewed enthusiasm for the procedure, it is important to understand the various indications and contraindications for using patellofemoral arthroplasty devices with the expectation that proper patient selection will improve outcome. Our purpose was to analyze the appropriate usage of these prostheses based on published historical results. A literature search was done to review the indications, contraindications, and factors contributing to the failure of these devices. We analyzed 12 studies reporting results of patellofemoral arthroplasty between 1979 and 2005. Commonly cited contraindications for using these devices have been tibiofemoral arthritis, uncorrected patellofemoral or tibiofemoral malalignment, and inflammatory arthritis. The highest failure rates were in patients with progression of osteoarthritis in other compartments or persistence of congenital or surgically uncorrected malalignment. In analyzing the reasons for failures in these reports together with issues already known to affect total knee arthroplasty surgery, we suggest an expanded list of outcome-altering factors to consider when choosing to do a patellofemoral arthroplasty. Finally, based on these observations and our own experience, suggestions on the best approach to the patient with patellofemoral arthritis are made to avoid less than optimal results if patellofemoral arthroplasty is considered. LEVEL OF EVIDENCE: Prognostic Study, Level II-3 (systematic review of Level-II studies. See the Guidelines for Authors for a complete description of levels of evidence.

Free gracilis tendon graft in neglected tears of the achilles tendon.

OBJECTIVE: To report the results of a longitudinal study on reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft. DESIGN: Cohort study. PARTICIPANTS: Twenty-one patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and 9 months before the operation. METHODS: All participants were prospectively followed up for 2 years, and final review was performed at 28.4 +/- 3.5 months from the operation. Functional (anthropometric measurements, isometric strength, return to activities) and clinical assessment was performed. RESULTS: No patients experienced any problems in the wound used to harvest the tendon of gracilis. Five patients were managed conservatively following a superficial infection of the Achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a rerupture. All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at final review. The operated limb was significantly less strong than the nonoperated one. CONCLUSIONS: The management of neglected tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of a duration of 9 months. These patients should be warned that they are at risk for postoperative complications, and that their ankle plantar flexion strength can remain reduced.

Femoral supracondylar stress fractures: an unusual cause of knee pain.

Supracondylar stress fractures are rare and can cause anterior knee pain. Persistent, intense pain occurs in the knee and distal thigh and may be mistaken for patellofemoral pain syndrome unless the fracture is identified by radiographic modalities (MRI or bone scan). Two cases of supracondylar femoral stress fractures in female runners highlight the need to seek proximal pathologies when patients report knee pain that cannot be explained by other conditions.