A new and simple method for patellar height measurement: Fibula-condyle-patella angle.

OBJECTIVES: This study aims to evaluate the inter-observer reliability of fibula-condyle-patella angle measurements and to compare it with other measurement techniques. PATIENTS AND METHODS: Between January 01, 2023 and January 31, 2023, a total of 108 patients (20 males, 88 females; mean age: 47.5±12.0 years; range, 18 to 72 years) who underwent X-rays using the fibula-condyle-patella angle, Insall-Salvati, Caton-Deschamps, Blackburne-Pell, and plateau-patella angle (PPA) methods were retrospectively analyzed. Knee lateral radiographs taken in at least 30 degrees of flexion and appropriate rotation were scanned. All measurements were made by two orthopedic surgeons who were blinded to measurement methods. RESULTS: Right knee patellar height measurements were conducted in 56 patients, while left knee patellar heights were assessed in 52 patients. The highest inter-observer concordance was found in the fibula-condyle-patella angle. The second highest concordance was found in the Insall-Salvati. The highest concordance correlation was found with PPA in the measurements of both researchers. CONCLUSION: The fibula-condyle-patella angle is a reliable technique with a good inter-observer reliability for measuring patellar height. We believe that this study will inspire future research to establish comprehensive reference values for clinical applications.

Evaluation of the relationship between the anatomical characteristics of the vastus medialis obliquus muscle and the patella chondral lesion occurrence.

OBJECTIVES: The study aims to investigate the relationship between the vastus medialis obliquus (VMO) muscle distal insertion features and patellar chondral lesion presence. PATIENTS AND METHODS: This cross-sectional study included a total of 100 patients (18 males, 82 females, mean age 67.2±7.1 years; range, 50 to 86 years) who underwent total knee arthroplasty (TKA). Radiological assessments, including merchant view and standing orthoroentgenograms, were conducted. The current osteoarthritis stage, varus angle, quadriceps angle (Q angle), patella-patellar tendon angle (P-PT angle), congruence angle, and sulcus angle were calculated. The VMO tendon length, muscle fiber angle, tendon insertion width measurements, and patellar chondral lesion localization data were obtained intraoperatively. Grouping was done according to the distal insertion width of the VMO tendon to the medial edge of the patella. The medial rim of the patella was divided into three equal-sized sectors. The first group (Group 1, n=31) consisted of patients who had an insertion from the quadriceps tendon into the upper one-third of the patella. The second group (Group 1, n=48) consisted of patients with a distal insertion expanding into the middle one-third of the patella. The third group (Group 3, n=21) consisted of patients who had a distal insertion extending into the distal third region of the medial patella margin. The patella joint surface was divided into sectors, and the presence and location of cartilage lesions were noted in detail. RESULTS: The mean tendon insertion width rate was 45.99±16.886% (range, 16.7 to 83.3%). The mean muscle fiber insertion angle was 51.85±11.67º (range, 20º to 80º). The mean tendon length was 12.45±3.289 (range, 4 to 20) mm. There was no significant difference between the mean age, weight, height, body mass index, BMI, fiber angle, tendon length, varus angle, Q angle, sulcus angle, and congruence angle data among the groups. In terms of the P-PT angle, Groups 1 and 2 had a significant relationship (p=0.008). No relationship was found between the mean fiber insertion angle, mean tendon length, or the presence of chondral lesions. There was a statistically significant difference among the groups regarding the presence of chondral lesions. The highest percentage of chondral lesion frequency was observed in Group 3 (95.24%), followed by Group 1 (90.3%) and Group 2 (89.6%), respectively. Compared to the other two groups, Group 3 had a higher average ratio of lesion areas per patient. CONCLUSION: Our study results demonstrate that the formation and localization of the patellar chondral lesions are affected by the insertion width type of the VMO muscle into the patella. Group 2-type insertion is associated with a lower lesion frequency rate than Groups 1 and 3.

Relationship Between Prepatellar Fat Thickness and Bone Mineral Density.

OBJECTIVE: To evaluate the relationship between bone mineral density (BMD) by measuring the prepatellar fat thickness with knee radiography and to gain a measurement method that has not been done before in the literature. STUDY DESIGN: Cross-sectional descriptive study. Place and Duration of the Study: Department of Physical Medicine and Rehabilitation, Training and Research Hospital, Sanliurfa, Turkiye, between January and June 2020. METHODOLOGY: Patients' age, body mass index (BMI) data, prepatellar fat thickness (mm), L1-L4 total, bone mineral density femoral neck, femur trochanter major, and femur total T scores were recorded. The relationships between these three groups (normal, osteopenia, osteoporosis) and between prepatellar fat tissue measurement were evaluated. One-way analysis of variance (ANOVA) and Post Hoc Tukey tests were used in the analysis. RESULTS:  A statistically significant difference was found in terms of trochanter major T score measurements (X2 = 20.435; p <0.001) and BMI (X2 = 66.535; p <0.001) measurements of prepatellar fat thickness measurement. A statistically significant difference was found between the three groups in terms of prepatellar fat thickness measurement, L1-4 T-score, femoral neck, and femur total values (p <0.001). CONCLUSION:  Prepatellar fat thickness in postmenopausal Turkish women was positively correlated with BMD; BMD increases as the prepatellar fat thickness increases. This explains that perapatellar fat thickness creates a mechanical load on the bones and causes an increase in BMD. KEY WORDS: Osteoporosis, Fat thickness, Bone mineral density.

Tension band versus locking plate fixation for patella fractures - a protocol of a randomised controlled trial.

INTRODUCTION: Following surgical management of patella fractures, patients commonly report pain; difficulties with weight-bearing tasks such as walking, running and climbing stairs; and restrictions in quality of life. Recently, a locking plate system for surgical management of patella fractures has been introduced. To date, no studies have compared standard treatment with tension band wiring with locking plate fixation in a randomised study design. We aim to compare the one-year patient-reported Knee Injury and Osteoarthritis Outcome subscale scores (KOOS5-subscales) after standard care tension band fixation with locking plate fixation for patients with patella fractures. METHODS: This is a multicentre randomised and prospective clinical trial. A total of 122 patients will be included in the study, and the primary outcome will be the KOOS subscales at 12 months after surgery. CONCLUSIONS: Findings from the present study are expected to advance our understanding of outcome following surgical treatment of patella fractures. FUNDING: This study is funded, in part, by the Novo Nordisk Foundation, Denmark. CLINICALTRIALS: gov ID: NCT04891549.

Study on the therapeutic effect of Kirschner wire tension band combined with anchor cross-stitch technique in the treatment of comminuted patellar inferopolar fractures.

PURPOSES: Fractures of the inferior patellar pole, unlike other patellar fractures, present challenges for traditional surgical fixation methods. This article introduces the clinical technique and outcomes of using Kirschner wire tension band combined with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures. METHODS: This retrospective case series study included 14 patients with comminuted inferior patellar pole fractures treated at our institution from September 1, 2020, to April 30, 2022. All patients underwent surgery using the Kirschner wire tension band with anchor screw cross-stitch technique. Follow-up assessments involved postoperative X-rays to evaluate fracture healing, as well as clinical parameters such as healing time, Visual Analog Scale (VAS) scores, range of motion (ROM), and Bostman scores. RESULTS: All patients were followed for an average of over 12 months, with no cases of internal fixation failure. Knee joint stability and function were excellent. X-rays revealed an average healing time of approximately 10.79 ± 1.53 weeks, hospitalization lasted 5.64 ± 1.15 days, surgery took approximately 37.86 ± 5.32 minutes, and intraoperative blood loss was 33.29 ± 8.15 ml. One patient experienced irritation from the internal fixation material. At the final follow-up, the Bostman score averaged 28.29 ± 0.83, knee joint flexion reached 131.07° ± 4.88°, all patients achieved full knee extension, and the VAS score was 0.36 ± 0.63. CONCLUSION: Kirschner wire tension band with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures delivered satisfactory clinical outcomes. This surgical method, characterized by its simplicity and reliability, is a valuable addition to clinical practice.

Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging' revisited: a case-report.

BACKGROUND: People with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature. CASE PRESENTATION: In this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient's unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach. CONCLUSIONS: The limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Patellar Instability: Imaging Findings.

Patellofemoral instability results from impaired engagement of the patella in the trochlear groove at the start of flexion and may lead to pain and lateral patellar dislocation. It occurs most frequently in adolescents and young adults during sporting activities. Trochlear dysplasia, patella alta, and excessive lateralization of the tibial tuberosity are the most common risk factors for patellar instability. The main role of imaging is to depict and assess these anatomical factors and highlight features indicating previous lateral dislocation of the patella.

Effect of soft tissue tension around the knee joint on medio-lateral patellar position.

Patellofemoral pain (PFP) is one of the most common sports injuries of the knee joint and has a high persistence and recurrence rate. Medio-lateral patellar position in the knee extension position during contraction is associated with PFP. However, soft tissue tension that most influences the medio-lateral patellar position in the knee extension position during contraction in vivo is unclear. We aimed to clarify the relationship between medio-lateral patellar position and soft tissue tension around the knee joint. Twelve patients with PFP and 20 healthy participants were included. Medio-lateral patellar position and tension of the rectus femoris, vastus lateralis (VL), vastus medialis, iliotibial band (ITB), lateral patellofemoral ligament, and medial patellofemoral ligament were measured during contraction and rest. The tensions of the VL and ITB during contraction and the medio-lateral patellar position at rest were significantly associated with medio-lateral patellar position during contraction (ß = 0.449, 0.354, and 0.393, respectively). In addition, the tension of ITB was significantly associated with the medio-lateral patellar position at rest (ß = 0.646). These relationships were not affected by the presence of PFP. These findings suggest that the patellar position during contraction became more lateral as the tension in the VL and ITB increased, regardless of the presence of PFP. These results may facilitate the prevention and treatment of PFP.

Sensitivity to change and responsiveness of provocative load tests among athletes with patellar tendinopathy.

BACKGROUND: Pain provocation tests are recommended for assessing pain severity and as an outcome measure for individuals with patellar tendinopathy. OBJECTIVE: To evaluate floor and ceiling effects, sensitivity to change, and responsiveness cut-offs of two provocative load tests among athletes with patellar tendinopathy. METHODS: Athletes (N = 41) performed six repetitions for the single leg decline squat (SLDS) and resisted knee extension (KE) at baseline and 12 weeks. Participants rated their pain during each test on a visual analog scale (VAS). Sensitivity to change was assessed by calculating effect size (ES) and the standardized response mean (SRM). The responsiveness cut-offs were assessed using a combination of anchor and distribution- based methods to determine the minimal clinically important difference (MCID) for each test. RESULTS: A floor or ceiling effect was observed in only a small number of participants for both tests except for KE, for which approximately one third of participants had a floor effect at week 12. There was higher sensitivity to change for SLDS (ES: 1.93/SRM: 1.43) compared with KE (ES:0.96/SRM: 1.09). The MCID corresponded to a decrease of 1.6 points for SLDS and 1.0 for KE, while the distribution-based method estimated 1.2 points for SLDS and 1.1 for KE. CONCLUSION: This study found moderate to high sensitivity to change and established MCID values for the SLDS and KE test in athletes with patellar tendinopathy before and after rehabilitation. Both tests may be useful as pain on loading outcomes as athletes progress with their rehabilitation, but the KE test results in higher floor effects and has lower sensitivity to change.

Patella Cartilage Status Does Not Affect the Clinical Outcomes of Non-resurfaced Patella in Mobile-Bearing Total Knee Arthroplasty.

Background: During total knee arthroplasty (TKA), patellar retention is performed when the cartilage is fairly well preserved and the thickness of the patella is relatively thin. However, clinical outcomes of the non-resurfaced patella in TKA according to the cartilage status are lacking in the literature. The purpose of this study was to compare patient-reported outcome measures (PROMs) according to the grade and location of the patellar cartilage lesion in TKA patients. Methods: The outcomes of 165 osteoarthritis patients (186 knees) who underwent cemented mobile-bearing TKA without patellar resurfacing were assessed and classified according to the grade and location of the patellar cartilage lesion. PROMs using the Western Ontario and MacMaster Universities Osteoarthritis index, the Knee Society Score (Knee Society Function Score and Knee Society Knee Score), and the Hospital for Special Surgery score were evaluated preoperatively and at postoperative 2, 4, 6, and 8 years. The correlations between PROMs and the grade and location of the cartilage lesion were assessed. Additionally, radiologic outcomes including the patellar tilt angle and patellar height were assessed and their correlation with the grade of cartilage lesion was analyzed. Analysis of variance was used to determine statistical significance. Results: There was no significant difference between PROMs according to the grades and locations of cartilage lesions at any postoperative follow-up. Radiologic parameters also showed no significant differences according to the grades of patellar cartilage lesions. Conclusions: The grade and location of the patellar cartilage lesion had no influence on clinical outcomes in mobile-bearing TKA with patellar retention at short- and long-term follow-up.

Reconstruction of the extensor mechanism using polypropylene mesh in a displaced pathological fracture of the patella affected by giant cell tumour.

A man in his 30s came to our clinic with a year-long history of progressive pain and swelling in his knee. Diagnostic imaging revealed a displaced patellar fracture with an osteolytic, septated lesion and thinned expanded cortex in both fracture fragments. A core needle biopsy confirmed the diagnosis of giant cell tumour. Treatment involved wide excision of the tumour and the use of polypropylene mesh and a peroneal longus tendon autograft to reconstruct the extensor mechanism of the knee joint. One year postoperatively, the patient experienced no pain, demonstrated full range of motion and showed no signs of functional impairment or local tumour recurrence. This case highlights that reconstruction of the extensor mechanism of the knee after tumour excision with synthetic mesh is an affordable, user-friendly and widely accessible method. It can address large defects effectively while minimising the risks of disease transmission and graft lengthening, resulting in satisfactory outcomes.

The Importance of Medial Patellar Shape as a Risk Factor for Recurrent Patellar Dislocation in Adults.

BACKGROUND: Research on the cause of lateral patellar dislocation (LPD) has focused on trochlear morphologic parameters, joint alignment, and patellofemoral soft tissue forces. A paucity of information is available regarding how patellar morphologic parameters influence the risk for LPD. PURPOSE/HYPOTHESIS: The purpose was to assess whether patellar morphology is a risk factor for recurrent LPD. It was hypothesized that (1) patients with recurrent LPD would have decreased patellar width and volume and (2) patellar morphologic parameters would accurately discriminate patients with recurrent LPD from controls. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 21 adults with recurrent LPD (age, 29.7 ± 11.1 years; height, 170.8 ± 9.9 cm; weight, 76.1 ± 17.5 kg; 57% female) were compared with 21 sex- and height-matched controls (age, 27.2 ± 6.7 years; height, 172.0 ± 10.6 cm; weight, 71.1 ± 12.8 kg; 57% female). Three-dimensional axial fat-saturated magnetic resonance imaging scans were used to measure patellar medial, lateral, and total width; patellar volume; patellar medial and lateral facet length; the Wiberg index; and previously validated knee joint alignment and femoral shape measurements (eg, tibial tuberosity to trochlear groove distance, trochlear dysplasia). RESULTS: The LPD group demonstrated reduced medial patellar width (Δ = -3.6 mm; P < .001) and medial facet length (Δ = -3.7 mm; P < .001) but no change in lateral width or facet length. This resulted in decreased total patellar width (Δ = -3.2 mm; P = .009), decreased patellar volume (Δ = -0.3 cm3; P = .025), and an increased Wiberg index (Δ = 0.05; P < .001). No significant differences were found for all other patellar shape measures between cohorts. Medial patellar width was the strongest single discriminator (83.3% accuracy) for recurrent LPD. Combining medial patellar width, patellofemoral tilt, and trochlear groove length increased the discrimination to 92.9%. CONCLUSION: The medial patellar width was significantly smaller in patients with recurrent LPD and was the single most accurate discriminator for recurrent LPD, even compared with traditional trochlear shape and joint alignment measures (eg, trochlear dysplasia, patella alta). Therefore, medial patellar morphology should be assessed in patients with LPD as a risk factor for recurrence and a potential means to improve treatment.

Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons.

BACKGROUND: Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma. METHODS: A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections). RESULTS: A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001). CONCLUSION: The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

Outcome of surgical correction of medial patellar luxation in dogs weighing less than 10 kg.

BACKGROUND: Various trochleoplasty techniques, including trochlear wedge recession (TWR) and trochlear block recession (TBR), are used to treat dogs with medial patellar luxation (MPL). However, the objective outcomes of these surgical procedures are underreported. METHODS: Medical records were obtained for dogs weighing less than 10 kg that underwent either TWR or TBR and tibial tuberosity transposition to address grade I-III MPL. Long-term (at least 1 year after the last procedure) follow-up included orthopaedic and radiographic examinations, such as osteoarthritis score (OAS), ground reaction force (GRF) analysis and canine brief pain inventory (CBPI). RESULTS: Overall, 20 dogs (26 stifles) were followed up in the long term. Minor postoperative complications, medial patellar reluxation (MPR) and intermittent lameness occurred in 46.15%, 19.23% and 15% of the dogs, respectively. MPR occurred only in TWR-treated stifles, while mean OAS increased in all groups. Using the CBPI, the owners perceived an excellent or very good outcome in 95% of dogs. LIMITATIONS: The limitations of the study include its retrospective observational nature, a lack of randomisation and a small sample size. CONCLUSION: Surgical treatment resulted in a favourable outcome. GRF analysis could detect subtle differences in weight bearing in dogs treated for MPL, which might not be apparent clinically. There might be a higher risk for reluxation for TWR. However, a larger-scale prospective study would be required to find which treatment is superior.

Changes in Patellar Height and Tibial Posterior Slope after Biplanar High Tibial Osteotomy with Computer-Designed Personalized Surgical Guides: A Retrospective Study.

OBJECTIVE: Medial opening-wedge high tibial osteotomy (MOWHTO) is a surgical procedure to treat medial compartment osteoarthritis in the knee with varus deformity. However, factors such as patellar height (PH) and the sagittal plane's posterior tibial slope angle (PTSA) are potentially overlooked. This study investigated the impact of alignment correction angle guided by computer-designed personalized surgical guide plate (PSGP) in MOWHTO on PH and PTSA, offering insights for enhancing surgical techniques. METHODS: This retrospective study included patients who underwent 3D-printed PSGP-assisted MOWHTO at our institution from March to September 2022. The paired t-tests assessed differences in all preoperative and postoperative measurement parameters. Multivariate linear regression analysis examined correlations between PTSA, CDI (Caton-Deschamps Index), and the alignment correction magnitude. Receiver operating characteristic (ROC) curve analysis determined the threshold of the correction angle, calculating sensitivity, specificity, and area under the curve. RESULTS: A total of 107 patients were included in our study. The CDI changed from a preoperative mean of 0.97 ± 0.13 (range 0.70-1.34) to a postoperative mean of 0.82 ± 0.13 (range 0.55-1.20). PTSA changed from a preoperative mean of 8.54 ± 2.67 (range 2.19-17.55) to a postoperative mean of 10.54 ± 3.05 (range 4.48-18.05). The t-test revealed statistically significant changes in both values (p < 0.05). A significant alteration in patellar height occurred when the correction angle exceeded 9.39°. Moreover, this paper illustrates a negative correlation between CDI change and the correction angle and preoperative PTSA. Holding other factors constant, each 1-degree increase in the correction angle led to a 0.017 decrease in postoperative CDI, and each 1-degree increase in preoperative PTSA resulted in a 0.008 decrease in postoperative CDI. PTSA change was positively correlated only with the correction angle; for each 1-degree increase in the opening angle, postoperative PTS increased by 0.188, with other factors constant. CONCLUSION: This study highlights the effectiveness and precision of PSGP-assisted MOWHTO, focusing on the impact of alignment correction on PH and PTSA. These findings support the optimization of PSGP technology, which offers simpler, faster, and safer surgeries with less radiation and bleeding than traditional methods. However, PSGP's one-time use design and the learning curve required for its application are limitations, suggesting areas for further research.

Effect of Patellar Morphology on the Risk of Osteochondral Fracture after Patellar Dislocation: A Cross-sectional Study.

OBJECTIVE: The risk of osteochondral fracture (OCF) after patellar dislocation has been shown to be related to patellofemoral anatomy, but its relationship to patellar morphology remains unknown. The aim of this study was to investigate the associations between patellar morphology and the risk of OCF after patellar dislocation. METHODS: A total of 140 patients with patellar dislocation between January 2018 and June 2023 were enrolled in this study and divided into two groups. Sixty-five patellar dislocation patients with OCF were included in the OCF group, while 75 patellar dislocation patients without OCF were included in the non-OCF group. Computed tomography was used to compare measurements of patellar morphology including Wiberg classification, patellar width and thickness, Wiberg angle, Wiberg index, facet ratio, lateral patellar facet angle, and patellar tilt angle. A logistic regression model was performed to evaluate the correlations between patellar morphology and the risk of OCF after patellar dislocation. Receiver operating characteristic curves were used to calculate the area under the curve (AUC) and determine the diagnostic values of patellar morphology for OCF after patellar dislocation. Subgroup analyses for gender and age were conducted to compare the differences in patellar morphology of PD patients. RESULTS: Wiberg angle was significantly lower in the OCF group (p = 0.017), while Wiberg index (p = 0.002) and facet ratio (p = 0.023) were significantly higher in the OCF group. According to the results of logistic regression analysis, Wiberg angle (odds ratio [OR] = 0.96, p = 0.022) and Wiberg index (OR = 1.105, p = 0.032) were the final relevant factors for the occurrence of OCF after patellar dislocation. The AUC was 0.622 (95% confidence interval [CI]: 0.529-0.714) for Wiberg angle, 0.65 (95% CI: 0.558-0.742) for Wiberg index, and 0.702 (95% CI: 0.615-0.788) for the combination of Wiberg angle plus Wiberg index. CONCLUSION: Wiberg angle and Wiberg index were independent risk factors for the occurrence of osteochondral fracture after patellar dislocation. Moreover, Wiberg angle, Wiberg index, and the combination of Wiberg angle plus Wiberg index had good predictive diagnostic value for the occurrence of OCF after patellar dislocation.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach.

INTRODUCTION: According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches. METHODS: Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings. RESULTS: The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups. CONCLUSION: The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

Patellar osteochondritis dissecans: maturation-dependent patellofemoral joint characteristics.

BACKGROUND: The likelihood of healing of osteochondritis dissecans decreases with skeletal maturity and there are theories that abnormal biomechanical forces contribute to the development and progression of these lesions. OBJECTIVE: To characterize, according to regional skeletal maturity, the morphology and alignment indices of the patellofemoral joint on MRI in patients with patellar osteochondritis dissecans. MATERIALS AND METHODS: MRI examinations of patients with patellar osteochondritis dissecans obtained between January 2008 and May 2023 were retrospectively reviewed to determine regional skeletal maturity, osteochondritis dissecans lesion size and location, patellar and trochlear morphology (Wiberg/Dejour classifications), and to calculate trochlear sulcus angles, trochlear depth index, lateral trochlear inclination, Insall-Salvati index, Caton-Deschamps index, patellar tendon-lateral trochlear ridge, and tibial tubercle-trochlear groove distances. Values were compared between skeletally immature and mature groups. RESULTS: Sixty-eight children (22 girls, 46 boys, age: 14.0 ± 1.7 years) yielded 74 knees with patellar osteochondritis dissecans lesions, 14 (19%) of which were skeletally mature. The most common anatomic location was over the central patella [median ridge (34/74 - 46%) on the axial images and over the middle third (45/74 - 61%) on the sagittal images]. Overall, mean trochlear sulcus angle (high, 151 ± 11°), trochlear depth index (low, 2.8 ± 1.4 mm), and Insall-Salvati index (borderline, 1.3 ± 0.1) were abnormal for the entire sample. Skeletally mature knees were significantly more likely to have higher (more dysplastic) Dejour types when compared to skeletally immature knees (p < 0.01). Knees in the mature group, compared to immature, had significantly more abnormal mean lateral trochlear inclination (15 ± 8° vs. 19 ± 6°, p = 0.03) and patellar tendon-lateral trochlear ridge distance (5.55 ± 4.31 mm vs. 2.89 ± 4.69 mm, p = 0.04). Half of the knees had ≥ 4 abnormal features that predispose to patellofemoral maltracking; mature knees were significantly (p = 0.02) more likely to have a higher number of abnormal features (> 6 features, 7/14, 50.0%) versus immature knees (0-3 features, 33/60, 55.0%). CONCLUSION: In children with patellar osteochondritis dissecans, abnormal patellofemoral morphology and alignment indices were common in all patients and more severe in mature knees.