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

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

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

Because the results of treatment of osteochondritis dissecans of the femoral condyles are still not consistently satisfactory, we reviewed the cases of eighty-three patients (ninety-five knees) with osteochondritis dissecans who were followed for two to thirty-one years to identify factors that may influence treatment and long-term prognosis. Of the eighty-three patients, sixteen had only non-surgical treatment, sixty-five had only surgical treatment, and two had non-surgical treatment of one knee and surgical treatment of the other. Of the twenty-two knees (eighteen patients) that were treated non-surgically, fifteen were treated before and seven were treated after distal femoral epiphyseal closure. Of the seventy-three knees (in sixty-seven patients) that were treated surgically because of persisting symptoms, twenty-three were treated before epiphyseal closure and fifty, after closure. At follow-up, each knee was given a rating of excellent, good, fair, poor, or failure, and a corresponding point score. Seventy-seven per cent of the knees in the surgical group and 82 per cent of those in the conservatively treated group were rated either excellent or good. The average scores in both groups were higher in knees in which the osteochondritic defect was small and was treated before epiphyseal closure, and in knees in which the fragment healed as compared with the ones from which the fragment was removed. We found that knees with osteochondritis dissecans of the femoral condyles that had no other abnormal physical findings or functional disability responded well to conservative treatment before epiphyseal closure.(ABSTRACT TRUNCATED AT 250 WORDS)

The posterior cruciate ligament, situated near the center of the knee, functions as the basic stabilizer and is located close to the axis of motion. We diagnosed and repaired thirty-two consecutive acute tears of the posterior cruciate ligament associated with tears of medial or lateral-compartment ligaments, or of both. Of the twenty-nine knees that we could evaluate, twenty-three demonstrated a 2+ to 3+ positive abduction or adduction stress test done in maximum extension and a positive anterior drawer test done in maximum internal rotation, while only nine had a definitely positive posterior drawer test. In all knees we repaired the tears, using the medial meniscus as a graft in nine knees in which the repair of the posterior cruciate ligament did not produce immediate adequate stability at operation. Five to sixteen years after operation, twenty of these twenty-nine knees were available for evaluation. The objective results were good in thirteen, fair in four, and poor in three.

We reviewed the clinical records and operative notes of seventeen consecutive patients who were treated by surgical repair for acute posterolateral rotatory instability in order to determine the diagnostic features of the instability and the effectiveness of our surgical repair in thirteen patients who returned for objective and subjective evaluation after a mean follow-up of 53.3 months. Sixteen of the seventeen knees had a positive external-rotation recurvatum test; fifteen, a positive adduction-stress test at 30 degrees of knee flexion; and twelve, a positive posterolateral-drawer test. Associated rotatory instabilities were found in ten of the seventeen knees, with anterolateral rotatory instability being the most frequent. Two patients had associated peroneal-nerve palsy. One or more components of the arcuate ligament complex were injured in all seventeen knees. None of the thirteen patients who were followed required subsequent reconstruction for any chronic instability. Of these thirteen, the results in 85 per cent were rated good subjectively and in 77 per cent, good objectively. Eighty-five per cent of these patients had returned to athletic activity at their preinjury level; the remaining 15 per cent did not participate in sports activities. A positive posterolateral-drawer test or external rotation recurvatum test, or both, was diagnostic of posterolateral rotatory instability. The adduction stress test at 30 degrees of knee flexion was usually positive, but was not diagnostic. Accurate diagnosis and treatment of posterolateral rotatory instability in the acute stage can result in subjectively and objectively acceptable knee function.

Because the results of treatment of osteochondritis dissecans of the femoral condyles are still not consistently satisfactory, we reviewed the cases of eighty-three patients (ninety-five knees) with osteochondritis dissecans who were followed for two to thirty-one years to identify factors that may influence treatment and long-term prognosis. Of the eighty-three patients, sixteen had only non-surgical treatment, sixty-five had only surgical treatment, and two had non-surgical treatment of one knee and surgical treatment of the other. Of the twenty-two knees (eighteen patients) that were treated non-surgically, fifteen were treated before and seven were treated after distal femoral epiphyseal closure. Of the seventy-three knees (in sixty-seven patients) that were treated surgically because of persisting symptoms, twenty-three were treated before epiphyseal closure and fifty, after closure. At follow-up, each knee was given a rating of excellent, good, fair, poor, or failure, and a corresponding point score. Seventy-seven per cent of the knees in the surgical group and 82 per cent of those in the conservatively treated group were rated either excellent or good. The average scores in both groups were higher in knees in which the osteochondritic defect was small and was treated before epiphyseal closure, and in knees in which the fragment healed as compared with the ones from which the fragment was removed. We found that knees with osteochondritis dissecans of the femoral condyles that had no other abnormal physical findings or functional disability responded well to conservative treatment before epiphyseal closure.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional disability should be proven before surgery is performed. If the knee demonstrates disability and simultaneously demonstrates muscle atonia and atrophy or contracture and imbalance, this dynamic support of the knee should be corrected preoperatively as far as possible and then the disability reevaluated before proceeding with surgery. A complete, documented knee examination must precede ancillary diagnostic procedures. Too often I see patients still in trouble with knees previously operated upon, who relate they had a cursory knee examination or no knee examination and were told that now there are modern diagnostic procedures such as arthrography and arthroscopy so they can be admitted to the hospital for these procedures with a resultant accurate diagnosis. This concept is not true! No ancillary procedure supercedes a knowledgeable history and clinical examination. The surgeon should operate only on the basis of objective demonstration of the need for operation, not on the basis of the history alone. In my estimation, rehabilitation accounts for 50 percent of a successful result following injury or operation. Remember, anatomy is the key to the knee.

Posterolateral rotatory instability of the knee, usually accompanied by other instabilities, is easily missed, misdiagnosed, and mistreated. The correct diagnosis requires a complete examination of the knee, including both the external rotation-recurvatum and posterolateral drawer tests. The most effective operative approach when the lesion is interstitial or at the site of the femoral attachment consists of advancing the arcuate ligament complex and its osseous attachment anteriorly and distally on the femur to support the arcuate ligament repair. When the lesion is distal and the arcuate ligament attachment to the tibia and fibula is loose, this area must be stabilized. In a consecutive series of 140 patients, 141 knees were reconstructed with this procedure. Ninety-five patients (ninety-six knees), with a follow-up of two to thirteen years, form the basis for this report. Seventy-one of the patients had undergone a combined total of 112 prior operations on the knee without functional recovery. After surgery directed at the arcuate ligament complex, eighty-two knees (85 per cent) were objectively rated as good; thirteen (14 per cent), as fair; and one, as poor. Subjectively, seventy-five (78 per cent) of the patients considered the result to be good; twenty-one (22 per cent), fair; and none, poor. Functionally, seventy-seven (80 per cent) of the knees were rated by the patient as good; sixteen (16 per cent), as fair; and three (4 per cent), as poor. This is the first report on the long-term results of reconstruction of the arcuate ligament complex for the correction of chronic posterolateral rotatory instability. The results demonstrate the effectiveness of the procedure.

Proximal and distal reconstruction of the leg extensor mechanisms has been developed and performed in 346 cases over a period of 25 years. Proximal extensor mechanism reconstruction produces very satisfactory results in over 70% of cases and continues to be the basic principle of surgical treatment for patellar subluxation. In patients with Q angles (angle between line of the quadriceps force and the direction of the patellar tendon) greater than 10 degrees distal reconstruction (patellar tendon transfer) is done in addition to, not in lieu of, the dynamic proximal reconstruction. Treatment of the chondromalacia developing secondary to altered extensor mechanism mechanics can be by simple chondrectomy provided that the causal mechanical abnormalities are modified.

This article defines the anterior cruciate ligament-deficient knee in terms of capsular instabilities. This definition lends itself to a better assessment of the associated pathology consisting of torn capsular ligaments, torn medial and lateral menisci, chondral fractures, subluxation of the patella, and acute contusion of the peroneal nerve. The specific incidence of torn medial meniscus was 70 per cent, with a torn lateral meniscus identified 77 per cent of the time.