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The American Journal of Sports Medicine Jun 2024Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its...
Early Postoperative Rapid Rehabilitation Yields More Favorable Short-term Outcomes in Patients Undergoing Patellar Realignment Surgery for Recurrent Patellar Dislocation: A Prospective Randomized Controlled Study.
BACKGROUND
Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its safety and effectiveness is lacking.
PURPOSE
To compare the short-term postoperative outcomes of early rapid rehabilitation with those of conservative rehabilitation in patients with RPD.
STUDY DESIGN
Randomized controlled trial; Level of evidence, 2.
METHODS
A total of 50 patients with RPD who underwent tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction were enrolled between January 2018 and February 2019. Postoperatively, the patients were randomly assigned to either the early rapid group (rapid group; n = 25 patients) or the conservative group (control group; n = 25 patients) for rehabilitation training. The rapid group underwent faster progression in weightbearing and range of motion (ROM) training. Knee joint functional scores, ROM, bilateral thigh circumference differences, and imaging data were recorded preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively for comparison. Postoperative complications were recorded over the 24-month follow-up period.
RESULTS
The baseline data did not significantly differ between the 2 groups. Postoperatively, compared with the control group, the rapid group had higher Tegner scores at 6 weeks and 3 months; higher Lysholm scores at 3 and 6 months; higher International Knee Documentation Committee scores at 6 weeks, 3 months, and 12 months; better ROM; and smaller bilateral thigh circumference differences at 24 months ( < .05 for all). However, no differences were observed in the Tegner, Lysholm, and International Knee Documentation Committee scores at 24 months postoperatively. At the 6-week and subsequent follow-up visits, the Caton and Insall indices were lower in the control group than in the rapid group ( < .01 for all). Moreover, compared with the control group, the rapid group had a lower incidence of patella baja at 24 months (0% vs 17%) and fewer complications during the whole follow-up period ( < .01).
CONCLUSION
Early rapid postoperative rehabilitation appears to be safe and effective for patients who undergo tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction to treat RPD. In the short term, this approach was shown to be more advantageous than conservative rehabilitation in improving functional scores, allowing an earlier return to daily activities, although the lack of difference at 24 months implies no long-term benefits. In addition, it potentially helped to prevent the occurrence of complications, including patella baja.
REGISTRATION
ChiCTR1800014648 (ClinicalTrials.gov identifier).
PubMed: 38884318
DOI: 10.1177/03635465241254524 -
Orthopaedic Journal of Sports Medicine Jun 2024Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic...
BACKGROUND
Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic medial patellar facet lesions.
PURPOSE/HYPOTHESIS
To identify clinical and radiographic risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability. It was hypothesized that a posterior tibial tubercle relative to the trochlear groove would be a risk factor for atraumatic medial patellar facet lesions.
STUDY DESIGN
Case-control study; Level of evidence, 3.
METHODS
A total of 37 patients with atraumatic medial patellar facet lesions were matched by age, sex, and body mass index with 37 control patients without a history of patellofemoral dysplasia. Demographic and imaging characteristics were compared between groups. Plain radiography was used to evaluate Wiberg type, and magnetic resonance imaging was used to calculate Caton-Deschamps index, tibial tubercle-trochlear groove distance, trochlear facet asymmetry ratio, patellotrochlear index, sulcus depth, patellar bisect ratio, and tibial tubercle height. Statistically significant variables from univariate analysis were used as inputs to the multivariate regression model to assess independent risk factors.
RESULTS
There were no differences between groups with respect to Wiberg type, Caton-Deschamps index, tibial tubercle-trochlear groove distance, sulcus depth, or patellotrochlear index ( > .05 for all). The medial facet lesion group had a larger medial trochlear facet (trochlear facet asymmetry ratio, 0.72 ± 0.11 vs 0.60 ± 0.09; < .001), a more medial-lying patella in the trochlear groove (patellar bisect ratio, 0.57 ± 0.06 vs 0.55 ± 0.07; = .035), and a more posterior tibial tubercle relative to the trochlear groove (tibial tubercle height, -3.13 ± 5.21 vs -0.23 ± 5.93 mm; = .030) compared with the control group. Multivariate regression analysis identified trochlear facet asymmetry and tibial tubercle height as independent risk factors for medial patellar facet lesions (relative risk = 97.3 [95% CI, 14.9-635.1], < .001 and relative risk = 0.95 [95% CI, 0.92-0.98], = .004, respectively).
CONCLUSION
A relatively larger medial trochlear facet and a more posterior tibial tubercle relative to the trochlear groove were found to be risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability.
PubMed: 38881850
DOI: 10.1177/23259671241255681 -
The Knee Jun 2024This study aimed to evaluate the effects of the differences in initial graft tension (IGT) on patellofemoral alignment in the axial plane after anatomical anterior...
BACKGROUND
This study aimed to evaluate the effects of the differences in initial graft tension (IGT) on patellofemoral alignment in the axial plane after anatomical anterior cruciate ligament reconstruction (ACLR).
METHODS
A total of 102 patients who underwent primary anatomical ACLR using a bone-patellar-tendon-bone autograft were enrolled. The grafts were fixed with maximum manual force at full knee extension (higher graft tension; H group) and with 5-20 N at 20° knee flexion which corresponded to 80 N at full knee extension (lower graft tension; L group) pulls in 39 and 63 patients, respectively. All patients underwent computed tomography of the bilateral knee joints with knee extension 1 week postoperatively. The patellofemoral alignment (sulcus angle, lateral trochlear inclination angle, lateral patellofemoral angle (LPFA), condylar-patellar angle (CPA) (lateral facet, patellar tilt), congruence angle, and bisect offset index) on the axial computed tomography images were evaluated, and the side-to-side differences (SSDs) between the injured knee and the contralateral knee were calculated.
RESULTS
Congruence angle SSD was remarkably higher in the H group than in the L group (3.8 ± 4.7 vs. 0.4 ± 5.7, P < 0.01). Furthermore, the LPFA SSD and CPA (patellar tilt) SSD were significantly higher in the H group (-1.8 ± 3.1 vs. -0.4 ± 2.7, P = 0.04 and -1.6 ± 2.8 vs. -0.3 ± 2.7, P = 0.04, respectively).
CONCLUSIONS
A higher IGT during anatomical ACLR induces a lateral shift and tilt of the patella against the femur immediately after surgery compared with the lower IGT.
PubMed: 38880041
DOI: 10.1016/j.knee.2024.05.011 -
Hand Surgery & Rehabilitation Apr 2024Congenital nail disorders are an uncommon presenting symptom which can be difficult to diagnose and manage. Nail diseases in the pediatric population differ from those... (Review)
Review
Congenital nail disorders are an uncommon presenting symptom which can be difficult to diagnose and manage. Nail diseases in the pediatric population differ from those in adults in terms of diagnosis, approach and management. In most cases, they do not require treatment and resolve with growth. Physicians need to be able to recognize them, to reassure the parents. The most frequently encountered pathologies associated with nail disorder are syndactyly, acrosyndactyly, symbrachydactyly, macrodactyly, Wassel I thumb duplication, Kirner's deformity and congenital onychodysplasia of the index finger. Treatment usually consists in surgical correction of the deformity. Nail malformation can also be an aspect of a systemic disease. It may provide a clue for screening, and should not be overlooked. Nail conditions can be the first sign of nail-patella syndrome, ectodermal dysplasia, dyskeratosis congenita, epidermolysis bullosa, pachyonychia congenita or lung disease. Medical treatment is therefore discussed on a case-by-case basis.
Topics: Humans; Nails, Malformed; Nail Diseases; Ectodermal Dysplasia
PubMed: 38879228
DOI: 10.1016/j.hansur.2023.01.011 -
Asian Journal of Surgery Jun 2024
PubMed: 38876864
DOI: 10.1016/j.asjsur.2024.05.289 -
Journal of Pediatric Orthopedics Jun 2024Despite representing over half of all pediatric patella fractures, inferior pole patellar sleeve fractures (PSFs) are a relatively uncommon pediatric injury. As a...
BACKGROUND
Despite representing over half of all pediatric patella fractures, inferior pole patellar sleeve fractures (PSFs) are a relatively uncommon pediatric injury. As a result, existing literature on PSFs is limited to case reports and small case series. The purpose of this study was to evaluate the radiographic and clinical characteristics of operatively treated PSFs as well as outcomes following surgical management.
METHODS
A retrospective review of all inferior pole PSFs requiring surgery from 2007 to 2023 was performed at a single urban tertiary care children's hospital. Cases were identified using diagnostic and billing codes. Patient demographics, injury characteristics, surgical techniques, and postoperative rehabilitation practices were recorded. Regional skeletal maturity, fracture characteristics, and postreduction patellar height were recorded. Postoperative complications were recorded and categorized using the modified Clavien-Dindo Classification System (CDS).
RESULTS
Thirty-eight inferior pole PSFs were identified meeting study criteria. The majority of patients were male (86.8%), and the mean age at injury was 11.0 years (range: 7.2 to 15.0). Mean BMI was 21.1. Radiographically, the majority of patients were Epiphyseal Fusion Stage 0 (nonunion), with a median postreduction Caton-Deschamps index (CDI) of 1.2 (IQR: 1.1 to 1.3). These fractures were predominantly treated with suture-based fixation (84%). Postoperative immobilization varied within the cohort, and the initiation of knee ROM was permitted at a median of 3.5 (IQR: 2.0 to 4.6) weeks. All patients regained full range of motion and straight leg raise without extensor lag, and return-to-sport was achieved by a median of 17.6 weeks (IQR: 12.8 to 30.3). Complications occurred in 10 (26.3%) patients, with 3 (7.9%) requiring a return to the OR (CDS Grade III).
CONCLUSIONS
Inferior pole PSFs appear to occur most commonly among prepubertal males of normal BMI and normal patellar height. Despite variable rehabilitation protocols, operative management resulted in restoration of extensor mechanism function. Eight percent of patients experienced complications requiring unplanned surgery. This large series improves our understanding of the epidemiology, injury characteristics, and postoperative outcomes of an operatively treated cohort of a rare injury pattern.
LEVEL OF EVIDENCE
Level IV.
PubMed: 38873923
DOI: 10.1097/BPO.0000000000002730 -
Canadian Prosthetics & Orthotics Journal 2023Residual limb discomfort and injury is a common experience for people living with lower limb amputation. Frequently, inadequate load distribution between the prosthetic...
BACKGROUND
Residual limb discomfort and injury is a common experience for people living with lower limb amputation. Frequently, inadequate load distribution between the prosthetic device and the residual limb is the root cause of this issue. To advance our understanding of prosthetic interface fit, tools are needed to evaluate the mechanical interaction at the prosthetic interface, allowing interface designs to be evaluated and optimised.
OBJECTIVE
Present a methodology report designed to facilitate comprehension of the mechanical interaction between the prosthetic interface and the residual limb. As a pilot study, this methodology is used to compare a hands-on and hands-off interface for a single transtibial prosthesis user using secondary Magnetic Resonance Imaging (MRI) data.
METHODOLOGY
MRI data of the residual limb while wearing a prosthetic interface is segmented into a hard tissue and a skin surface model. These models are exported as stereolithography (STL) files. Two methods are used to analyse the interface designs. Firstly, CloudCompare software is used to compute the nearest vertex on the skin surface for every vertex on the compiled internal bony surface for both interface types. Secondly, CloudCompare software is used to compare registered skin surfaces of the residual limb while wearing the hands-on and hands-off interfaces.
FINDINGS
The maximum and minimum nearest distances between the internal bony surface and skin surface were similar between interface types. However, the distribution of nearest distances was different. When comparing the skin surface while wearing both interfaces, where the fit is more compressive can be visualized. For the dataset used in this study, the classic features of a hands-on Patella Tendon Bearing interface and hands-off pressure cast interface could be identified.
CONCLUSION
The methodology presented in this report may give researchers a further tool to better understand how interface designs affect the soft tissues of the residual limb.
PubMed: 38873008
DOI: 10.33137/cpoj.v6i1.42196 -
The Journal of Knee Surgery Jun 2024This study aimed to evaluate the mechanical properties of bone plug fixation to the tibia with a novel device, the Bone plug Tensioning and Fixation (BTF) system.Forty...
This study aimed to evaluate the mechanical properties of bone plug fixation to the tibia with a novel device, the Bone plug Tensioning and Fixation (BTF) system.Forty bone-tendon-bone grafts consisting of the whole patella-patellar tendon-tibial bone plug of 10-mm width and tibiae from the porcine were prepared. After creating a 10-mm tibial tunnel, the tibial bone plug was fixed to the tibia with the BTF system or the interference screw (IFS) to prepare a test specimen of the patella-patellar tendon-tibial bone plug fixed to the tibia. For the graft tension controllability study, a predetermined initial tension of 9.8 or 19.6 N was applied and maintained for 5 minutes. Then the bone plug was fixed to the tibia with the BTF system or IFS in 10 specimens, monitoring the residual tension for an additional 5 minutes. Then, a cyclic loading test and a tension-to-failure test were performed.The mean difference between the residual tension and the predetermined tension was significantly smaller in BTF fixation (9.8 N → 10.6 ± 2.2 N; 19.6 N → 18.9 ± 2.1 N) than in IFS fixation (9.8 N → 23.4 ± 7.4 N; 19.6 N → 28.9 ± 11.5 N). The mean displacement of the bone plug after cyclic loading was significantly less in the BTF group (1.2 ± 0.6 mm) than in the IFS group (2.2 ± 1.0 mm; < 0.01). Stiffness was significantly greater in the BTF group (504.6 ± 148.8 N/mm) than in the IFS group (294.7 ± 96.7 N/mm; < 0.01), whereas the maximum failure loads in the two groups did not differ significantly (724.2 ± 180.3 N in the BTF and 634.8 ± 159.4 N in the IFS groups).BTF system better performed in graft tension controllability than IFS did. BTF fixation was superior to IFS fixation in the displacement of the bone plug during the cyclic loading test and in stiffness in the tension-to-failure test.
PubMed: 38870989
DOI: 10.1055/a-2344-5195 -
Surgical and Radiologic Anatomy : SRA Jun 2024The suprapatellar bursa is located in the proximal deep layer of the patella and is thought to reduce tissue friction by changing from a single-membrane structure to a...
PURPOSE
The suprapatellar bursa is located in the proximal deep layer of the patella and is thought to reduce tissue friction by changing from a single-membrane structure to a double-membrane structure during knee joint motion. However, the dynamics of the suprapatellar bursa have only been inferred from positional relationships, and the actual dynamics have not been confirmed.
METHODS
Dynamics of the suprapatellar bursa during knee joint motion were observed in eight knees of four Thiel-fixed cadavers and the angle at which the bursa begins to show a double membrane was revealed. The flexion angles of knee joints were measured when the double-membrane structure of the suprapatellar bursa began to appear during knee joint extension.
RESULTS
The suprapatellar bursa changes from a single membrane to a double-membrane structure at 91 ± 4° of flexion, when the knee joint is moved from a flexed position to an extended position.
CONCLUSION
The suprapatellar bursa may be involved in limitations to knee joint range of motion and pain at an angle of approximately 90°. Further studies are needed to verify whether the same dynamics are observed in living subjects.
PubMed: 38856943
DOI: 10.1007/s00276-024-03390-1 -
Orthopaedic Journal of Sports Medicine Jun 2024While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of... (Review)
Review
BACKGROUND
While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes.
PURPOSE
To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique.
STUDY DESIGN
Systematic review.
METHODS
A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups.
RESULTS
Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt.
CONCLUSION
Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.
PubMed: 38855071
DOI: 10.1177/23259671241241537