Rehabilitation improves walking kinematics in children with a knee varus: Randomized controlled trial.

BACKGROUND: Previous studies have demonstrated increased medial stresses in knee varus alignment. Selecting a suitable treatment strategy for individuals with knee malalignment should be a priority. OBJECTIVES: We aimed to investigate the effects of a 16-week corrective exercise continuum (CEC) program on 3-D joint angles of the dominant and non-dominant lower limbs in children with genu varus during walking. METHODS: Overall, 28 male children with genu varus (age range 9-14 years) volunteered to participate in this study. They were randomly divided into 2 equal groups (experimental and control). The participants of the experimental group received CEC for 16 weeks. 3-D gait analysis involved using a Vicon Motion System. Paired and independent sample t-tests were used for within- and between-group comparisons, respectively. RESULTS: For the experimental group, comparison of pre- and post-test joint kinematics of the dominant lower limb revealed that CEC decreased the peak ankle dorsiflexion angle by 26% (P=0.020), peak foot internal rotation angle by 53% (P=0.001), peak knee internal rotation angle by 40% (P=0.011), peak hip abduction by 47% (P=0.010), and peak hip external rotation angle by 60% (P=0.001). In contrast, peak knee external rotation angle of the dominant limb was increased after the training program by 46% (P=0.044). For the non-dominant lower limb, CEC decreased the peak ankle inversion by 63% (P<0.01), peak ankle eversion by 91% (P<0.01), peak foot internal rotation by 50% (P<0.01), peak knee internal rotation by 29%; P=0.042), peak hip abduction angle by 38% (P<0.01), and peak hip external rotation angle by 60% (P<0.01). CONCLUSIONS: CEC therapy reduced excessive foot and knee internal rotations as well as excessive hip external rotation during walking in children with genu varus.

The effect of the native kinematics of the knee on the outcome following total knee arthroplasty.

AIMS: The aim of this study was to investigate differences in pain, range of movement function and satisfaction at three months and one year after total knee arthroplasty (TKA) in patients with an oblique pattern of kinematic graph of the knee and those with a varus pattern. PATIENTS AND METHODS: A total of 91 patients who underwent TKA were included in this retrospective study. Patients (59 women and 32 men with mean age of 68.7 years; 38.6 to 88.4) were grouped according to kinematic graphs which were generated during navigated TKA and the outcomes between the groups were compared. RESULTS: The graphs were varus in 50 patients (55%), oblique in 19 (21%), neutral in 17 (18.5%) and valgus in five (5.5%). After adjustment for pre-operative scores and gender, compared with patients with varus knee kinematics, patients with an oblique kinematic graph had a poorer outcome with lower Knee Society scores at three months (9.2 points, p = 0.038). CONCLUSION: We found four distinct kinematic graphs in knees and that patients with an oblique graph have a poorer outcome in the short-term after TKA. Cite this article: Bone Joint J 2016;98-B:1471-8.

Neuromuscular versus quadriceps strengthening exercise in patients with medial knee osteoarthritis and varus malalignment: a randomized controlled trial.

OBJECTIVE: To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the knee adduction moment (an indicator of mediolateral distribution of knee load), pain, and physical function in patients with medial knee joint osteoarthritis (OA) and varus malalignment. METHODS: One hundred patients with medial knee pain, mostly moderate-to-severe radiographic medial knee OA, and varus malalignment were randomly allocated to one of two 12-week exercise programs. Each program involved 14 individually supervised exercise sessions with a physiotherapist plus a home exercise component. Primary outcomes were peak external knee adduction moment (3-dimensional gait analysis), pain (visual analog scale), and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index). RESULTS: Eighty-two patients (38 [76%] of 50 in the NEXA group and 44 [88%] of 50 in the QS group) completed the trial. There was no significant between-group difference in the change in the peak knee adduction moment (mean difference 0.13 Nm/[body weight × height]% [95% confidence interval (95% CI) -0.08, 0.33]), pain (mean difference 2.4 mm [95% CI -6.0, 10.8]), or physical function (mean difference -0.8 units [95% CI -4.0, 2.4]). Neither group showed a change in knee moments following exercise, whereas both groups showed similar significant reductions in pain and improvement in physical function. CONCLUSION: Although comparable improvements in clinical outcomes were observed with both neuromuscular and quadriceps strengthening exercise in patients with moderate varus malalignment and mostly moderate-to-severe medial knee OA, these forms of exercise did not affect the knee adduction moment, a key predictor of structural disease progression.

The effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis.

This report describes and evaluates a physical therapy intervention in a 15-year-old male handball player with low grade isthmic spondylolisthesis and associated spinopelvic misalignment (shear-stress type). Upon examination, increased lumbar lordosis, horizontal sacrum and anterior pelvic tilting were mainly associated with altered resting length and extensibility of the iliopsoas, hip adductors and erector spinae muscles. The intervention was directed at improving the muscles resting length and extensibility balance within a global postural alignment perspective (global postural reeducation). After the treatment period, lumbar lordosis, sacral slope and anterior pelvic tilting decreased 17.2°, 16.5° and 15.1° respectively. Global postural reeducation was effective in changing spinopelvic alignment related to low grade isthmic spondylolisthesis. This treatment option should be considered as a potential nonsurgical alternative for this condition.

Clinical and ultrasonographic evidence of a proximal positional fault of the radius. A case report.

Positional faults are considered a possible underlying mechanism mimicking the symptoms of a joint sprain. Despite numerous clinical studies indicating the presence of positional faults, there is limited evidence of imaging studies confirming positional faults. This case report is a preliminary study that offers clinical and ultrasonographic evidence of a proximal positional fault of the radius, treated successfully with manual therapy techniques. Three weeks after a bike fall on the outstretched hand, the patient in this study presented with right wrist pain and a lack of progress with conventional conservative treatment (NSAIDs, rest and immobilization). Clinical findings indicating a proximal positional fault of the radius included pain during active pronation increased by associating a passive movement of the radius in a proximal direction and it was reduced by associating a passive movement of the radius in a distal direction. Ultrasonographic (US) images showed a reduction of radio-capitellar distance on the right side (11.4 mm) compared to the left side (13.3 mm). A positive response with a distal mobilization of the radius supported the proximal positional fault of the radius. After two manual therapy sessions, the patient had recovered normal asymptomatic function. The outcomes used to assess function and pain were active pronation range of motion, the Spanish version of the DASH questionnaire and a 0-10 numeric pain rating scale. Each measure was conducted prior and after each treatment session and one week post treatment. The patient was re-examined at 6 months follow-up, during which US images, demonstrated a normalization of the right radio-capitellar distance.

Reproducibilidad interevaluador del Formato de ObservaciónSistemática de la Alineación Corporal en estudiantes universitarios / Inter-rater reliability of the Body Alignment Systematic Observation Form in college students

Objetivo: Estimar la reproducibilidad interevaluador del Formato de Observación Sistemáticade la Alineación Corporal (FOSAC), aplicado a adultos jóvenes de una universidad privada deBucaramanga (Colombia).Metodología: Se realizó un estudio de pruebas diagnósticas en una muestra de 123 estudiantesuniversitarios de 18 a 29 a˜nos de edad, que cumplieran con los criterios de inclusión establecidos.Tres examinadores (un experto en postura, una fisioterapeuta con experiencia y unaestudiante de último semestre de fisioterapia) realizaron el examen postural, analizando 7 fotografíasimpresas: una posterior, 2 laterales derechas, 2 laterales izquierdas y 2 anteriores. Seexaminaron 63 deficiencias que fueron registradas en el FOSAC.Resultados: La reproducibilidad interevaluador para determinar deficiencias posturales oscilóentre pobre y aceptable. Los planos que obtuvieron mejor reproducibilidad de acuerdo alíndice kappa global fueron el lateral izquierdo y derecho, en los cuales el 35,7% de las deficienciasobtuvo un kappa por encima de 0,40. Escoliosis en S fue la deficiencia con mayorreproducibilidad en el ítem experto vs. estudiante en el plano posterior, con un valor kappa de1,00.Conclusiones: La baja reproducibilidad interevaluador conduce a considerar que la exploraciónpostural por observación directa no es el método adecuado para usar en investigaciones. Sinembargo, permite al profesional detectar deficiencias posturales marcadas; por esta razón,no debería ser excluida del proceso de evaluación fisioterapéutica. Por otra parte, el FOSACpuede constituirse en una herramienta útil en la formación académica del futuro profesional enfisioterapia, al establecer metódicamente el proceso de observación de la alineación corporal (AU)

Objective: To estimate the inter-rater reliability of the Body Alignment Systematic ObservationForm (BASOF) applied to young adults in a private university in Bucaramanga (Colombia).Methodology: A study of diagnostic tests was performed in a sample of 123 college students,aged 18 to 29, who met the inclusion criteria. Three examiners (an expert in posture, a physiotherapistwith experience and a last semester student of physiotherapy) performed the posturalexamination, analyzing 7 printed photographs: one posterior, two right laterals, two left lateralsand two anterior. We studied 63 deficiencies, which were registered in the BASOF.Results: The inter-rater reliability to determine postural deficiencies ranged from poor toacceptable. The level obtaining the best reliability according to the global Kappa index wasthe posterior one in which 26.5% of the deficiencies obtained a kappa Index greater than0.40. The scoliosis in S variable had the highest reliability with a kappa value of 1.00, obtainedon the item expert vs student on the posterior plane.Conclusions: The low inter-rater reliability leads to the conclusion that postural examination bydirect observation method is not suitable for use in research. However, it allows the practitionerto detect marked postural deficiencies and therefore should not be excluded from the physiotherapyexamination. Moreover, the BASOF can become a useful tool in the future academiccareer in physical therapy to establish methodically the process of observing body alignment (AU)

Functional impact of tibial malrotation following intramedullary nailing of tibial shaft fractures.

BACKGROUND: Tibial malrotation is a complication that is seen in approximately 30% of patients following locked intramedullary nailing. In this cohort study, we evaluated the hypothesis that tibial malrotation would lead to impaired functional outcomes. METHODS: Patients with a unilateral tibial shaft fracture who were managed with intramedullary nailing between 2003 and 2007 were identified with use of ICD-10 (International Classification of Diseases, 10th Revision) codes. After institutional review board approval and written informed consent had been obtained, specific assessment of eligible patients was achieved with use of computed tomography, functional measures (Lower Extremity Functional Scale, Olerud-Molander Score, six-minute walk test), and physical examination. Measures were compared between patients with and without tibial malrotation (defined as tibial rotation of ≥ 10°) on imaging studies. RESULTS: Of the 288 patients who were identified, 100 were eligible for the study and seventy consented to participate. The mean duration of follow-up (and standard deviation) for these seventy patients was 58 ± 11 months. Twenty-nine patients (41%) had tibial malrotation. Lower Extremity Functional Scale scores were similar between the groups with and without malrotation (mean, 70.8 ± 8.6 points compared with 72.6 ± 8.7 points; p = 0.41). The results for the other functional tests were also similar. CONCLUSIONS: Despite high rates of tibial malrotation following locked intramedullary nailing of isolated tibial diaphyseal fractures, this finding does not have a significant intermediate-term functional impact.

Rehabilitative protocols for select patellofemoral procedures and nonoperative management schemes.

There is a paucity of evidence-based care protocols for the management of patellofemoral (PF) joint conditions. There remains ambiguity in defining conditions; PF pain, malalignment, instability are intersecting patient cohorts in clinical practice. Treatment should address muscle strength deficits as well as movement pattern dysfunctions frequently observed in association with PF conditions. Quadriceps muscle dysfunction has significant heterogeneity in its etiology. The hip contributes to PF pathology as a consequence of femoral internal rotation and adduction. Inadequate gluteus medius ans maximus muscle performance is associated with kinematic flaws. Various surgical procedures are employed to address PF instability and associated pain patterns. Postoperative progressions should respect specific demands for bony healing, soft tissue healing and/or ligamentous graft incorporation. Symptomatic cartilage lesions may limit return to full function. Physical performance testing activities can be useful to measure patient progress and advise on return to activity/play.

Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge.

BACKGROUND: Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis. DESCRIPTION OF TECHNIQUE: An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability. METHODS: A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores. RESULTS: As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort. CONCLUSIONS: This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation. LEVEL OF EVIDENCE: Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Modified tension band for displaced type 2 lateral end clavicle fractures.

PURPOSE: Displaced type 2 lateral end clavicle fractures have a tendency to delayed union or non-union. Various methods of stabilisation of the displaced lateral end fractures are described. The increasing use of implants to fix such fractures also necessitates extensive dissection for implant retrieval. Adequate reduction and minimal tissue trauma during implant placement and removal would be ideal modalities for fixation of such fractures. METHODS: All displaced type 2 lateral end clavicle fractures fulfilling our inclusion criteria were reduced with a small anterosuperior incision. Anteroposterior drill holes were made in both the fragments and a nonabsorabable polyester suture was passed through. The fracture was reduced and fixed with transacromial smooth Kirshner wires. The suture was tied with the knot superiorly in a figure-eight manner. The arm was supported in an arm pouch for six weeks. The Kirshner wire was routinely removed after six weeks in an out-patient department. Clinico-radiological outcome was studied at six weeks, and monthly intervals thereafter until union. RESULTS: All 16 fractures united. The mean average age of patients was 36.25 years with a SD of 11.35. There was no loss of reduction even after removal of Kirshner wires at six weeks. The mean average time of union was 10.75 weeks with a SD of 3.92. All patients regained near normal range of motion, and the mean average constant score at the end of one year was 98.37 with a SD of 2.87. All patients returned to preinjury level by the one-year follow-up. The range of motion remained the same in those who were followed up in successive years. Skin impingement with bent Kirshner wires were noted in four cases. Kirshner wires backed out in one case before six weeks but there was no loss of reduction. Infection and Kirshner wire breakage were not noted in our series. CONCLUSION: The clinico-radiological outcomes with our modified tension band fixation for displaced type 2 lateral end clavicle fractures were encouraging and comparable with earlier studies.

Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study.

BACKGROUND: Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF). QUESTIONS/PURPOSES: We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate. METHODS: We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6-40 months). RESULTS: All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients. CONCLUSIONS: The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Resistance training for medial compartment knee osteoarthritis and malalignment.

PURPOSES: 1) To evaluate the effects of a 12-wk high-intensity knee extensor and flexor resistance training program on strength, pain, and adherence in patients with advanced knee osteoarthritis and varus malalignment and 2) to generate pilot data for change in dynamic knee joint load, patent-reported outcomes, and self-efficacy after training. METHODS: Fourteen patients (48.35 +/- 6.51 yr) with radiographically confirmed medial compartment knee osteoarthritis and varus malalignment of the lower limb were recruited from a surgical waiting list for high tibial osteotomy. Participants completed a high-intensity isokinetic resistance training program three times per week for 12 wk. Knee extensor and flexor strength were assessed every third week, whereas pain and adherence were recorded at every training session. The external knee adduction moment during the gait, the 6-min-walk test, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Arthritis Self-Efficacy Scale (ASES) were also evaluated before and after training. RESULTS: Significant improvements in knee extensor and flexor strength were observed without increases in pain during or after training. Adherence to the high-intensity program was high. No significant changes were observed for dynamic knee joint load or the KOOS. There was a significant increase in the function subscale of the ASES only. CONCLUSIONS: These findings suggest that patients with advanced knee osteoarthritis and malalignment can experience substantial gains in strength after a high-intensity resistance training program without concomitant increases in pain, adverse events, or compromised adherence. These findings provide support for future clinical trials with longer-term outcomes.

A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis.

OBJECTIVE: In uncontrolled studies, a lateral-wedge insole has reduced knee pain in patients with medial knee osteoarthritis (OA). The aim of this study was to test the efficacy of this simple, low-cost intervention for pain in patients with medial knee OA. METHODS: We conducted a double-blind, randomized, crossover trial designed to detect a small effect of treatment. Participants were at least 50 years of age and had medial joint space narrowing on posteroanterior semiflexed radiographs and scores indicating moderate pain for 2 of the 5 items on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale. Participants were randomized to receive a 5 degrees lateral-wedge insole or a neutral insole for 6 weeks. Following a 4-week washout period, participants crossed over to the other treatment for 6 weeks. Knee pain, the primary outcome, was assessed by the WOMAC pain scale (visual analog scale version). Secondary outcomes included the WOMAC disability subscale, overall knee pain, 50-feet walk time, chair-stand time, and use of medications for knee pain. RESULTS: Ninety patients were randomized. The mean difference in pain between the 2 treatments was 13.8 points on the WOMAC pain scale (95% confidence interval -3.9, 31.4 [P=0.13]). We observed similar small effects for the secondary outcomes. CONCLUSION: The effect of treatment with a lateral-wedge insole for knee OA was neither statistically significant nor clinically important.

Correction of axis misalignment in the analysis of knee rotations.

The Cardanic or Eulerian description is the most commonly used method for the description of in vivo knee rotation. It is based on the determination of external anatomical landmarks used for the decomposition of the position of the tibia relative to the femur by three rotations about three pre-defined axes. However, the in vivo localisation of external anatomical landmarks is known to be difficult and subjective. Even a small mislocalisation may lead to dramatic consequences: the Cardanic description may become irreproducible and angle values may be overestimated. This error is well documented in the literature and known as the "cross-talk effect". Therefore this study proposes an additional calibration step of the classic Cardanic description by a reorientation procedure of rotation axes. The procedure is based on biomechanical constraints of knee kinematics as they appear during a knee squat exercise using the finite helical axis (FHA) method and is independent of anatomical landmark. The method was validated with the help of a special set-up modelling a perfect knee. Furthermore, an inter-session reliability study was performed involving tests on two healthy subjects during knee squat exercises. We found that the reorientation procedure was more reproducible than the classic Cardanic description. We observed a maximum inter-session difference of 37.1 degrees for the adduction angle obtained with the classic Cardanic description. In contrast, the maximum angle difference obtained with the reorientation procedure was less than 10 degrees.

Reliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student raters.

STUDY DESIGN: Test-retest reliability with blinded testers. OBJECTIVES: To determine the inter- and intra-rater reliability of the lateral pull test and patellar tilt test. BACKGROUND: If patellar malalignment can be detected by clinical examination, then condition-specific treatment interventions may be implemented in patients with patellofemoral pain syndrome. However, several clinical tests used to assess patellar mobility have recently been shown to have poor to fair reliability. Because the lateral pull test and the patellar tilt test are widely used clinically as diagnostic tests for patellofemoral pain syndrome but have not been previously tested for reliability, we examined these tests. METHODS AND MEASURES: Fifty-two subjects (age range, 21-48 years) provided 95 knees (19 symptomatic and 76 asymptomatic) for assessment of the lateral pull test. Two testers, blinded to the presence or absence of symptoms, independently performed the lateral pull test in random order. Fifty-five subjects (age range, 22-42 years) provided 99 knees (73 asymptomatic and 26 symptomatic) for assessment of the patellar tilt test. Three blinded testers independently performed the patellar tilt test in random order. All subjects were tested and retested within 3-5 days. A kappa (kappa) statistic was used to assess the agreement of findings within each tester and between testers. RESULTS: The kappa coefficients for intrarater reliability varied from 0.39 to 0.47 for the lateral pull test and from 0.44 to 0.50 for the patellar tilt test, while the coefficients for interrater reliability were 0.31 for the lateral pull test and varied from 0.20 to 0.35 for the tilt test. CONCLUSIONS: Repeated lateral pull tests and patellar tilt tests had fair intrarater and poor interrater reliability. Our results suggest that care must be taken in placing too much emphasis on these tests when making clinical decisions.

Evaluation of the effectiveness of a metacarpophalangeal ulnar deviation orthosis.

Rheumatoid arthritis (RA) causes structural damage that precipitates joint deformity, including metacarpophalangeal (MCP) joint ulnar drift (UD). Orthoses have been designed in order to maintain hand function by improving joint alignment, restoring biomechanical balance and reducing stress on supporting diseased tissues. This study investigated the impact an MCP UD (MUD) splint had on: pain, hand function, grip strength, and passive correction of UD when worn for function by RA patients. Twenty seven hands (26 subjects) were evaluated and performances compared with and without the splint. Results showed anatomic alignment improved significantly in all except the index finger. The mean difference for all fingers combined was 10 degrees. Observable correction of subluxation was identified from x-ray film and noted in 14.8% of index fingers, 18.5% of middle fingers, 33.3% of ring fingers, and 48.1% of little fingers. Three point pinch showed a statistically significant change, the mean difference being an improvement of 15% while wearing the splint. There was no significant change in hand function score, pain score, gross grip strength, and lateral pinch. Subjects' perceptions of the MUD splint gained from a questionnaire showed a high acceptance: 79.2% reporting minimal interference in ADL, 95.8% satisfied with cosmesis, 87.5% satisfied with comfort, and 95.8% reported continued use of the orthosis.

Lower quarter screening for skeletal malalignment--suggestions for orthotics and shoewear.

Skeletal malalignments of the lower quarter, deformities within a bone or at a joint, may be the primary cause of musculoskeletal patient problems. Skeletal malalignments also may sustain the presence of a musculoskeletal patient problem that has some other causal mechanism. A screening exam for skeletal alignment of the lower quarter may assist clinicians in identifying skeletal malalignments that are associated with a musculoskeletal complaint. The purposes of this paper are to: 1) describe components for a skeletal alignment screening exam, 2) analyze how lower quarter malalignments may influence lower quarter function and contribute to the development of musculoskeletal pathology, and 3) suggest general characteristics of foot orthoses and shoes that may assist in the management of musculoskeletal patient problems of the lower quarter.

Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle.

Forty patients underwent 45 modified Elmslie-Trillat realignment procedures (mean followup, 2 years) for refractory patellar instability (34 knees) or painful patellofemoral syndrome with malalignment (11 knees). The postoperative congruence angle (mean, +3.4 degrees) was significantly improved compared with the preoperative value (mean, +21.5 degrees). We considered the "normal" congruence angle average as -8 degrees (range, -20 degrees to +4 degrees). Over time postoperatively, we detected no statistical difference in the congruence angle (5 months, 3.4 degrees; 24 months, 6.3 degrees). There were no patellar dislocations postoperatively. Nine knees (20%) had some postoperative subluxation. Ninety-four percent of the patients without subluxation had congruence angles less than 15 degrees, whereas 54% of patients with postoperative subluxation had postoperative congruence angles greater than 15 degrees. The evidence in this study population indicates that the modified Elmslie-Trillat procedure can predictably improve the patellar congruence angle. Adequate correction may eliminate patellar dislocation. Correction of the congruence angle to less than +15 degrees will result in a decreased incidence of postoperative patellar instability. Early full activity postoperatively did not affect the modified Elmslie-Trillat correction of the congruence angle being maintained over time.