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Purpose The purpose of this meta-analysis is to compare arthroscopic single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstructions in the light of all available randomised controlled trials (RCTs). A meta-analysis of this well-researched topic was performed and subgroup analyses of the medial portal (MP) technique and the transtibial technique (TT) were added as a new idea. The hypothesis was that the DB technique is superior to the SB technique also in subgroup analyses of the MP and TT techniques. Methods Instructions of the PRISMA checklist were followed. Systematic literature search from electronic databases, including PubMed, Cochrane library and Scopus was performed to find RCTs that compared the SB and DB techniques. Nine outcomes were used to compare these two techniques. Each study was assessed according to the Cochrane Collaboration’s risk of bias tool and three subgroup analyses (minimum 2-years’ follow-up, TT technique and MP technique) were performed. Results A total of 40 studies were included in this meta-analysis. When analysing all the included studies, the DB technique was superior to the SB technique in KT-1000/2000 evaluation (p p p = 0.02), pivot shift (p p = 0.02). Similar results were also found in the subgroup analyses of minimum 2-years’ follow-up and the TT technique. However, there were no differences between the two techniques in a subgroup analysis of the MP technique. Conclusion Generally, DB ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than SB ACL reconstruction. The subgroup analysis of the MP technique revealed that surgeons can achieve equally as good results with both techniques when femoral tunnels are drilled through the medial portal. Level of evidence II.

Background: A traumatic lateral patellar dislocation is a common injury in adolescents and young adults. The majority of first–time dislocations can be treated nonoperatively. Various types of knee braces are used for nonoperative treatment, but evidence on the most preferable bracing method is lacking. Purpose: To evaluate the efficacy of a patella–stabilizing, motion-restricting knee brace versus a neoprene nonhinged knee brace for the treatment of a first–time traumatic patellar dislocation at 3 years of follow–up. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 101 skeletally mature patients with a first–time traumatic patellar dislocation were enrolled in the study. After exclusion criteria were applied, 79 patients with a first–time traumatic patellar dislocation were randomized and allocated into 2 study groups: group A, with a patella–stabilizing, motion-restricting knee brace (hinged to allow knee range of motion [ROM] of 0°-30°) and group B, with a neoprene nonhinged knee brace (not restricting any knee motion). Both groups received similar physical therapy instructions and were advised to use the brace continuously for 4 weeks. Overall, 64 patients completed the trial. Results: The redislocation rate in group A was 34.4% (11/32) and in group B it was 37.5% (12/32) (risk difference, –3.1% [95% CI, –26.6% to 20.3%]; P = .794). Patients in group A had less knee ROM than those in group B at 4 weeks (90° vs 115°, respectively; P < .001) and 3 months (125° vs 133°, respectively; P = .028). Patients in group A had more quadriceps muscle atrophy than patients in group B at 4 weeks (24/32 vs 16/32, respectively; P = .048) and 3 months. At 6 months, patients in group B reported better functional outcomes than patients in group A (Kujala score mean difference, 4.6; P = .012), although no clinically relevant difference was found at 3 years. Conclusion: The use of a patella–stabilizing, motion-restricting knee brace for 4 weeks after a first–time traumatic patellar dislocation did not result in a statistically significant reduction in redislocations versus a neoprene nonhinged knee brace, although this trial was underpowered to detect more modest differences. Knee immobilization was associated with quadriceps muscle atrophy, less knee ROM, and worse functional outcomes in the first 6 months after the injury. Registration: NCT01344915 (ClinicalTrials.gov identifier).

BACKGROUND: The TMT-1 joint arthrodesis is a common repair for severe hallux valgus. Two crossing interfragmental screws, usually titanium or steel, and a locking plate or a plate with a compression screw are the most common fixation methods for first TMT joint arthrodesis. The qualities of an ideal fixation material include adequate strength and rigidity, biocompatibility, lack of interference with bone healing, lack of visibility and palpability, and a low risk of surgical removal. We sought to determine whether bioabsorbable cannulated screws would perform as well as titanium screws in anatomical models. METHODS: Identical anatomical TMT-1 arthrodesis was created with a saw by making a straight cut in 30 anatomical models (Sawbone®). The bioabsorbable and titanium screws were placed one at a time in exactly the same location in each model according to careful measurements. All 30 models were analyzed with a material testing machine (MTS Insight 30, Eden Prairie, USA). Each model was oriented 15° to the platform to simulate its position to the ground during mid-stance. RESULTS: In the single-cycle load-to-failure test, the mean yield load was 61.4 N ± 5.7 N (range, 50.1 N–70.3 N) in the bioabsorbable screw group and 81.2 N ± 12 N (range, 61.7 N–113.4 N) in the titanium screw group (P

BackgroundInjury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury.MethodsOne hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (ResultsFleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45– 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52–0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen’s kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6–92.4) and specificity was 85.3% (52.9–100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1%p = 0.003).ConclusionsDiagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle.Level of evidenceIII.

Background Many surgical procedures have been described for hallux valgus. Evidence provided by the current literature on the different procedures is, however, poor. The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and to find out whether changes in operation techniques of HV have occurred during the study period. Methods The study included all adult patients (≥18 years) who underwent primary HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data were collected by the Finnish National Hospital Discharge Register (NHDR). Results The total incidence of primary HV operations was 66.7 per 100,000 person-years in 1997 and 41.4 per 100,000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time the incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies. Conclusion This study shows a significant decreasing trend of HV operations in Finland between 1997 and 2014. During the study period, the incidence of MTP I joint arthroplasty decreased, and since 2005 the incidence of MT-1-osteotomies has almost halved. At the same time, the incidence of MTP-1 joint arthrodesis increased by over 1000% and TMT-1 joint arthrodesis by nearly 2000%.

BackgroundCurrent knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries.MethodsIn this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire.ResultsIn total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery.ConclusionNonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies.Level of evidenceIV, retrospective case series

Background and purpose — Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures. Patients and methods — The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register. Results — 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29–32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12–14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016. Interpretation — Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

Background The purpose of this study was to assess the nationwide incidence (per 100,000 person-years) of operative treatment and hospitalization due to calcaneal fractures (CF) in Finland. Methods The study was based on the Finnish National Hospital Discharge Register. All patients aged 18-years or older admitted to Finnish hospitals for primary treatment of CF in 1987–2012 were included. Results During the 26-year study period 5977 patients were hospitalized with main or secondary diagnosis of a CF. The incidence of hospitalization due to CF remained relatively stable: (12.5)/100,000 in men and 3.9/100,000 in women. The men were younger (median 43 years) than the women (median 61 years). Conclusions The incidence of the hospitalization due to CF in Finland has remained at steady level during the past 26 years. The incidence of CF is three times higher in men. In 2012 22% of the fractures were operatively treated.

For route planning and tracking, it is sometimes necessary to know if the user is walking or using some other mode of transport. In most cases, the GPS data can be acquired from the user device. It is possible to estimate user’s transportation mode based on a GPS trace at a sampling rate of once per minute. There has been little prior work on the selection of a set of features from a large number of proposed features, especially for sparse GPS data. This article considers characteristics of distribution, auto- and cross-correlations, and spectral features of speed and acceleration as possible features, and presents an approach to selecting the most significant, non-correlating features from among those. Both speed and acceleration are inferred from changes in location and time between data points. Using GPS traces of buses in the city of Tampere, and of walking, biking and driving from the OpenStreetMap and Microsoft GeoLife projects, spectral bins were found to be among the most significant non-correlating features for differentiating between walking, bicycle, bus and driving, and were used to train classifiers with a fair accuracy. Auto- and cross-correlations, kurtoses and skewnesses were found to be of no use in the classification task. Useful features were found to have a fairly large (>0.4) correlation with each other.

Background: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging–based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. Methods: All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. Results: During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. Conclusions: The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (Level of Evidence: Level III, epidemiologic study.

Lisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries. This study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period. This publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results. ClinicalTrials.gov identifier: NCT02953067 24.10.2016.

Background:Patellofemoral cartilage deterioration and osteoarthritis are reported to be associated with recurrent patellar dislocation. However, the association between first-time traumatic patellar dislocation and cartilage deterioration is unknown.Purpose:The aim of this study was to assess long-term cartilage deterioration in the patellofemoral and tibiofemoral joint after conservatively treated traumatic lateral patellar dislocation.Study Design:Case series; Level of evidence, 4.Methods:Twenty patients (mean age, 25 years) who sustained first-time traumatic lateral patellar dislocation with no previous patellofemoral instability symptoms were initially scanned with 1.5-T magnetic resonance imaging (MRI). A follow-up 3-T MRI was conducted, on average, 8 years after first-time lateral patellar dislocation. Subjective instability symptoms and Knee injury and Osteoarthritis Outcome Score were also assessed.Results:In the primary MRI, patellofemoral cartilage injury was seen in 14 of 20 patients (70%). Most (14/15) of the injuries were seen in the patellar cartilage, especially at the medial facet. On the follow-up MRI, patellofemoral cartilage deterioration was visible for all patients. The central patella ( P = .005) seemed especially prone to cartilage deterioration during the follow-up. Half of the patients (10/20) had grade 3-4 cartilage lesions in the patellofemoral joint in the follow-up MRI. In the primary MRI, only 1 patient exhibited tibiofemoral joint cartilage lesions, whereas at the time of follow-up, 10 of 20 patients exhibited tibiofemoral cartilage lesions. The majority of these lesions were considered clinically nonsignificant (International Cartilage Repair Society = 1) and were seen in the lateral compartment (6/10, 60%). Of the 14 patients (36%) with injury to the patellar cartilage, 5 reported subsequent instability of the patellofemoral joint, but this was not associated with more significant cartilage deterioration in the follow-up MRI compared with patients without redislocation.Conclusion:While recurrent lateral patellar dislocation is known to lead to degenerative process, a single first-time or infrequently recurring traumatic lateral patellar dislocation also seems to be associated with gradual cartilage deterioration. Traumatic lateral patellar dislocation might initiate gradual degeneration of the cartilage in the patellofemoral joint and can lead to the development of generalized knee osteoarthritis. Instability symptoms of the patellofemoral joint, however, were not related to the severity of the deterioration.

To define medial patellofemoral ligament (MPFL) injury characteristics at the patellar attachment and clinical outcome in patients with primary traumatic patellar dislocation and MPFL avulsion injury at the patella. Magnetic resonance imaging (MRI) was used to assess patients with primary (first-time) patellar dislocation and MPFL injury at the medial margin of the patella. Fifty-six patients with patellar attachment MPFL injury were enrolled in the study. Thirteen patients underwent surgical fixation of the avulsed MPFL and patellar medial margin osteochondral fracture, and the remaining patellar MPFL injures were treated nonoperatively. Forty-four patients were evaluated clinically at median four (range 1–10) years after patellar dislocation. The follow-up included evaluation of recurrent patellar instability, subjective symptoms, and functional limitations. Three types of patellar MPFL injuries were found; type P0 with ligamentous disruption at the patellar attachment, type P1 with bony avulsion fracture from the medial margin of the patella, and type P2 with bony avulsion involving articular cartilage from the medial facet of the patella. Of the patellar MPFL avulsion injuries that underwent initial surgical fixation, two patients (2/13) reported an unstable patella at follow-up. Fifty-five per cent (17/31) of patellar MPFL avulsion injuries that were treated nonoperatively had recurrent patellar instability (n.s.). The median Kujala score was 90 for patellar avulsion with surgical fixation and 86 for patellar avulsion without surgical fixation (n.s.). Patellar attachment MPFL injury showed three different patterns, classified as types P0, P1, and P2. MRI can be used to assess the injury pattern. Patellar MPFL avulsion injuries do not benefit from acute surgical repair compared with nonsurgical treatment. Type P2 patellar MPFL avulsion includes an osteochondral fracture that may require surgical fixation. Prognostic study, Level III.

Primary patellar dislocation injures the medial patellofemoral ligament (MPFL), the major soft-tissue stabilizer of the patella, which may lead to recurrent patellar instability. Recurrent patellar dislocation are common and may require surgical intervention. The variation in location of injury of the MPFL and the presence of an osteochondral fracture produces challenges in clinical decision making between nonoperative and operative treatment, including the surgical modality, to repair or reconstruct the MPFL. Current evidence suggests that not all primary dislocations should undergo the same treatment. MPFL reconstruction may theoretically be more reliable than repair, but the optimal time to perform additional bony corrections is not known. A normal or minor dysplastic patellofemoral joint may be suitable for nonoperative treatment, whereas a higher grade of trochlear dysplasia or other significant abnormalities may benefit from surgical treatment. In this paper, we present a treatment algorithm for primary patellar dislocation.

Stress fractures often occur in physically active individuals as a result of repetitive strenuous muscle and tendon forces acting on bones that have not adapted to such forces1-3. To our knowledge, the literature contains no reports of displaced longitudinal stress fractures of the patella requiring open reduction and internal fixation. The quadriceps muscle and patellar tendon produce extensive forces that can result in a displaced transverse patellar stress fracture2-7. The less strong vertical patellar restraints, including the medial patellofemoral ligament8, produce most of the ligamentous patellar stability in the lateral direction near knee extension8. In cases of acute traumatic patellar dislocation, the osseous structure of the patella is compromised mostly in the lateral direction—e.g., by avulsion of the medial patellofemoral ligament insertion—causing a medial margin fracture of the patella9. We are not aware of any previous reports of repetitive stress causing a displaced longitudinal patellar stress fracture. Here, we describe a case of a displaced longitudinal stress fracture of the patella in a female athlete. The patient was informed that data concerning the case would be submitted for publication, and she consented. An eighteen-year-old female athlete who played floorball (a popular European team sport that is a variant of floor hockey) presented with chronic anterior knee pain that had begun a few months previously without any specific injury event. She was an international-level athlete, and her training had become more difficult because of the persistent anterior knee pain; however, she continued to exercise at a reduced intensity. At the first visit to an orthopaedic surgeon, radiographs were considered to show normal findings and clinical examination revealed no specific findings other than anterior knee pain with some tenderness of the patella. She was diagnosed with nonspecific anterior …

Orthotic insoles are suggested to prevent low back pain. This randomized controlled study assessed if customised orthotic insoles prevent low back pain. Healthy military conscripts (n = 228; mean age 19 years, range 18-29) were randomly assigned to use either customised orthotic insoles (treatment group, n = 73) or nothing (control group, n = 147). The main outcome measure was low back pain requiring a physician visit and resulting in minimum 1 day suspension from military duty. Twenty-four (33%) treated subjects and 42 (27%) control subjects were suspended from duty due to low back pain (p = 0.37; risk difference 4.3%; 95% CI: -8.7 to 17.3%). Mean suspension duration was 2 days (range 1-7) in both groups. Four (5%) treated subjects and eight (5%) control subjects were released from duty due to persistent low back pain (p = 0.92; risk difference 0%; 95% CI: -6 to 6%). Use of orthotic insoles is therefore not recommended to prevent physical stress-related low back pain.

In skeletally immature athletes, lateral patellar dislocation (LPD) is a common knee injury, which can lead to recurrent patellar dislocations in about half of the cases. The medial patellofemoral ligament (MPFL) is frequently injured in an acute LPD. Initial management should be nonoperative. Surgical stabilization is recommended after failure of appropriate nonoperative management. Reconstruction of the MPFL is a preferred surgical option for stabilization of the patella against lateral dislocations. In the skeletally immature knee, surgical techniques to stabilize the patella have focused on MPFL reconstructions, as operations that involve bone are contraindicated. Despite several published techniques for MPFL reconstruction, only techniques that do not involve drilling or disruption of the periosteum near the femoral physes are safe for the skeletally immature knee. An algorithm for treatment of LPD in the skeletally immature patient is presented with specific discussion of surgical technique options.

Lower limb overuse injuries are common among people who are exposed to physical stress. Orthotic shoe insoles are widely used to prevent lower limb overuse injuries. Here, we conducted a randomized-controlled study to examine whether the use of orthotic insoles prevents lower limb overuse injuries. Participants (n=228) were randomly assigned to use (n=73) or not to use (n=147) orthotic insoles. The insoles were molded to the shape of the foot to provide support during physical activity. The main outcome measure in the present study was the physician-diagnosed lower limb overuse injury. Thirty-four (46.6%) subjects in the insole group were diagnosed with a lower limb overuse injury compared with 56 (38.1%) in the control group (P=0.29) during the 6-month study period. When body mass index and the results of a 12-min running test and muscle strength were adjusted in a Cox's regression model, the hazard ratio for lower limb overuse injury in the insole group was 1.3 (95% confidence intervals: 0.8-2.1) compared with the control group. Use of orthotic insoles was not associated with a decrease in lower limb overuse injuries. Our findings suggest that routine use of orthotic insoles does not prevent physical-stress-related lower limb injuries in healthy young male adults.

There is no consensus about the management of acute primary traumatic patellar dislocation in young physically active adults. The objective of this study was to compare the clinical outcomes after treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation in young adults.Forty young adults, thirty-seven men and three women with a median age of twenty years (range, nineteen to twenty-two years), who had an acute primary traumatic patellar dislocation were randomly allocated to be treated with initial surgical stabilization (eighteen patients, with each receiving one of two types of initial stabilizing procedures) or to be managed with an orthosis (twenty-two patients, including four who had osteochondral fragments removed arthroscopically). After a median of seven years, thirty-eight patients returned for a follow-up examination. Redislocations, subjective symptoms, and functional limitations were evaluated. Radiographs and magnetic resonance images were obtained at the time of randomization, and twenty-nine (76%) patients underwent magnetic resonance imaging at the time of final follow-up.A hemarthrosis as well as injuries of the medial retinaculum and the medial patellofemoral ligament were found on magnetic resonance imaging in all patients at the time of randomization. During the follow-up period, six of the twenty-one nonoperatively treated patients and none of the seventeen patients treated with surgical stabilization had a redislocation (p = 0.02). Four nonoperatively treated patients and two patients treated with surgical stabilization reported painful patellar subluxation. The median Kujala scores were 91 points for the surgically treated patients and 90 points for the nonoperatively treated patients. Thirteen patients in the surgically treated group and fifteen in the nonoperatively treated group regained their former physical activity level. At the time of follow-up, a full-thickness patellofemoral articular cartilage lesion was detected on magnetic resonance imaging in eleven patients; the lesions were considered to be unrelated to the form of treatment.In a study of young, mostly male adults with primary traumatic patellar dislocation, the rate of redislocation for those treated with surgical stabilization was significantly lower than the rate for those treated without surgical stabilization. However, no clear subjective benefits of initial stabilizing surgery were seen at the time of long-term follow-up.

BackgroundNo data exist whether patients with primary traumatic patellar dislocation benefit from initial arthroscopic medial repair surgery.PurposeTo compare long-term outcomes of patients treated with acute arthroscopic stabilization for patellar dislocation with those treated nonoperatively except for removal of loose bodies.Study DesignCohort study; Level of evidence, 2.MethodsThe study group included 76 consecutive military recruits (72 men, 4 women), with a median age of 20 years (range, 19–22) at the time of dislocation. Thirty patients (group 1) underwent initial arthroscopic medial retinacular repair, and 46 patients (group 2) were treated without stabilizing surgery, including 11 who had osteochondral fragments arthroscopically removed. Patients with previous patellar dislocations or instability were excluded. Aftercare was identical in both groups. Redislocations, subjective symptoms, and functional limitations were evaluated after a median 7-year follow-up.ResultsSixty-one (80%) patients participated in a follow-up examination. At final follow-up, 8 (23%) redislocations occurred in group 2 and 5 (19%) in group 1 ( P = .84). Eight (23%) patients in group 2 and 3 (12%) in group 1 reported patellar subluxations ( P = .18). In group 1, 81% regained their preinjury activity level compared with 56% in group 2 ( P = .05). Functional outcomes were good in both groups (Kujala scores: 87 for group 1 and 90 for group 2) ( P = .22). Regarding the presence of osteoarthritic characteristics in the patellofemoral joint, no statistically significant differences were found between the groups.ConclusionsInitial arthroscopic medial retinacular repair was not followed by improved patellar stability nor reduced incidence of redislocations compared with nonoperative (except for removal of loose bodies) treatment. Acute arthroscopic medial retinacular repair allowed patients to better regain preinjury activity level than in patients not undergoing retinacular repair. The decision to stabilize the patella by initial arthroscopic surgery should be made with caution.

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

OBJECTIVE To investigate the clinical efficacy of zoledronic acid in patients with diabetes and acute Charcot neuroarthropathy. RESEARCH DESIGN AND METHODS Thirty-nine consecutive patients were randomly assigned to placebo or three intravenous infusions of 4 mg zoledronic acid. The primary outcome was clinical resolution of acute Charcot neuroarthropathy determined by total immobilization time (casting plus orthosis). RESULTS At baseline, there was no significant difference between the randomly assigned groups with respect to Charcot disease activity or other baseline values. In the zoledronic acid group, the median time for total immobilization was 27 weeks (range 10–62), and in the placebo group it was 20 weeks (20–52) (P = 0.02). CONCLUSIONS Zoledronic acid had no beneficial effect on the clinical resolution of acute Charcot neuroarthropathy in terms of total immobilization time. It is possible that it may prolong the time to clinical resolution of Charcot neuroarthropathy.

The occurrence of stress fractures in patients with long-standing rheumatoid arthritis (RA) is widely known. Osteoporosis, corticosteroid therapy, joint stiffness, contracture, angular deformity of the joint and failed joint reconstruction--all together or separately--predispose to bone loss and stress fractures. In the present report we describe the history of a girl with juvenile idiopathic arthritis (JIA) having multiple stress fractures. The relationship between corticosteroid therapy and immobilisation in the treatment of fractures is discussed.

Resume La survenue de fractures de contrainte chez des patientes atteintes d’une polyarthrite rhumatoide ancienne est bien connue. Les facteurs favorisant la perte osseuse et la survenue de ces fractures de contrainte, qui peuvent intervenir separement ou en association, sont multiples incluant l’osteoporose, la corticotherapie, la raideur articulaire, les contractures, les destructions et deformations articulaires. Nous rapportons ici le cas d’une fillette atteinte d’arthrite chronique juvenile qui developpe de multiples fractures de contrainte. Nous discutons les relations entre corticotherapie, immobilisation et fractures.

Objectives. In the present study we evaluated radiographically involvement of the ankle joint and its relationship with destruction of subtalar joint in rheumatoid arthritis (RA). Patients and methods. An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into 3 groups: no changes, minor changes and major changes. In the end point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade ≥ 2). Severity of RA in different groups was evaluated using the Larsen score of 0 – 100 of hands and feet. Difference between patient groups was evaluated using Cuzicks test. Results. At the end point major changes of the ankles were detected in 7 patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the 3-year follow-up in 2 patients. Fist major changes were detected at the 15-year follow-up in 3 ankles of 2 patients. Subtalar pathology preceded that of TC-joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but 2 ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0–100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzicks test for the trend was highly significant (p < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. Conclusion. Ankle joint is involved in a late stage of RA and it usually is affected only in the patients with severe disease. Subtalar pathology precedes the changes in talocrural joint almost regularly.

One hundred patients were treated nonoperatively for primary acute patellar dislocations, either by plaster cast (N = 60), by posterior splint (N = 17), or by patellar bandage or brace (N = 23). Follow-up exam inations were performed at an average of 13 years later (range, 6 to 26 years). Overall, there were 0.17 redislocations per follow-up year; the redislocation fre quencies per follow-up year for each patient group were 0.29, patellar bandages or braces; 0.12, plaster cast; and 0.08, posterior splint. In addition, there were fewer recurrences and subsequent problems (patel lofemoral pain or subluxations) in the group treated with posterior splints compared with the two other treatment groups. The most marked restrictions of knee joint movements were seen in the patients treated with plaster casts. Subjective assessment of treatment, however, did not differ significantly between the groups. Patients were also evaluated in relation to the treatment of redislocations and management of subsequent problems (i.e., patellofemoral pain or sub luxations). Patients who were treated operatively for their redislocations exhibited better outcomes than pa tients treated nonoperatively. In the patients who had subsequent problems, the operation did not relieve the symptoms.

One hundred patients with the diagnosis of an acute patellar dislocation treated conservatively and 30 healthy control subjects were studied roentgenographically by lateral and tangential views. The aim of the study was to determine the distribution and incidence of predisposing factors in different study groups. Three study groups were formed as follows: 67 patients (group A) without late problems or operative treatment of redislocation: 33 patients (group B) who underwent a surgical realignment procedure for redislocations or late problems; and 30 healthy control subjects (group C). A statistically significant difference was observed between the patient groups (A, B) and control group (C) when the means, medians and distributions of patellar tendon length (LT), patellar length (LP), tendon to patellar length ratio (LT/LP), tendon to patellar articular surface ratio (LT/LAS), sulcus angle (SA), lateral patellar displacement (LPD), lateral patellofemoral angle (LPA) and morphological classification of the patella (1–5, Jagerhut) were compared. In group A, LPD was also significantly greater than in group B. This study demonstrates a considerably high rate of predisposing factors associated with patellar dislocation.

Primary treatment of acute ankle ligament injury is almost always conservative. The more severe injury is, the more careful initial treatment, rehabilitation and follow-up is required. If the rupture of ligaments is suspected, the ankle must be supported with an air splint or ankle support. Functional therapy is initiated immediately upon the occurrence of the injury. Independent training by the patient is the cornerstone of functional therapy. Persistence of symptoms or recurrent injuries are often due to inadequate rehabilitation.

The clinical role of patellofemoral (PF) osteoarthrosis (OA) in the outcome after PF stabilizing surgery is poorly understood. The study hypothesis was that PF cartilage lesions and OA are associated with a poor long-term outcome after PF stabilizing surgery. The study cohort included thirty-seven patients who underwent PF stabilizing surgery by traditional nonanatomic procedures and were evaluated a minimum of 10 years (range 10–21) after surgery. PF OA was assessed by magnetic resonance (MR) images and plain radiographs obtained at follow-up. Median patient age at follow-up was 33 years (29–43). At the final follow-up, PF full-thickness cartilage lesions were observed on MR images in 29 (78%) patients. Only 46% of the patients reported satisfaction at follow-up, and dissatisfaction was associated with PF OA (full-thickness articular cartilage loss on MR images; P = 0.022). Especially high incidence, 89%, of medial patellar facet cartilage lesions were found among the patients dissatisfied with the result (16/18 patients) (n.s.). Eight (22%) of the 37 patients reported recurrent patellar instability episodes at follow-up. Median Kujala score was 83 points (range 55–98). Patellofemoral OA is a significant long-term risk of nonanatomic surgery for patellar instability and has a greater impact on subjective outcome than residual instability more than 10 years after surgery.

The aim of the study was to assess volumetric analysis of bone bruises in acute primary traumatic patellar dislocation by magnetic resonance imaging (MRI) and resolving resolution of bruises in follow-up MRI.MRI was performed in 23 cases. A follow-up examination was done at a mean of 12 months after dislocation. Volumes of patellar and femur bruises for every patient were evaluated separately by two musculoskeletal radiologists, and mean values of the bruises were assessed. Other MRI findings were evaluated, together with agreement by consensus. Bone bruise volumes were compared with other MR findings.In the acute study 100% of patients showed bruising of the lateral femoral condyle and 96% bruising of the patella. The bruise was located at the medial femoral condyle in 30% and at the patellar median ridge in 74% of patients. The median volume of the femoral bruise was 25,831 mm(3) and of the patellar bruise 2,832 mm(3). At the follow-up study 22% of patients showed bruising of the lateral femoral condyle and 39% bruising of the patella, the median volumes of the bruises being 5,062 mm(3) and 1,380 mm(3), respectively. Larger patellar bruise volume correlated with larger femur bruise volume in the acute (r = 0.389, P = 0.074) and the follow-up (r = 1.000, P0.01) studies. Other MRI findings did not correlate significantly with bone bruise volumes.Bone bruising is the commonest finding in cases of acute patellar dislocation, being seen even 1 year after trauma and indicating significant bone trabecular injury in the patellofemoral joint. A large bruise volume may be associated with subsequent chondral lesion progression at the patella. We concluded that the measurement of bone bruise volume in patients with acute patellar dislocation is a reproducible method but requires further studies to evaluate its clinical use.

Background There is only sparse scientific data about the long-term effects of the Charcot foot on patients' lives and the clinical outcome. This study evaluates the long-term effects of diabetic Charcot foot. Methods A cross-sectional follow-up study of consecutive series of patients with Charcot foot referred to the University Hospital Diabetic Foot and Ankle Clinic between 1991 and 2002. Results Forty-one patients were referred with Charcot foot between 1991 and 2002. After an average follow-up of 8 years their overall mortality rate was 29% (12/41) and 29 patients (30 Charcot feet) have been followed more than 5 years. Sixty-seven percent of Charcot feet suffered at least one episode of ulceration and 50% (15/30) of affected feet had surgical treatment resulting in 29 operations. Simple exostectomy was successful in 62% of cases. The need for surgical management increased markedly 4 years after the diagnosis. Correct diagnosis within 3 months resulted in better functional outcome (AOFAS) and walking distance ( p =0.006 and p =0.008, respectively). Lower SF-36 component scores in physical functioning, social functioning and general health perceptions were found when the study population was compared to the general population and chronically ill control subjects. Conclusions Diabetic Charcot foot decreases patient's physical functioning and general health but does not usually affect mental health. Surgical management is often required with an increase 4 years post-diagnosis. A delay of diagnosis of more than 3 months was found to adversely affect the quality of life and functional outcome.

Patellar dislocations are associated with injuries to the medial patellofemoral ligament (MPFL). Several techniques for MPFL reconstruction have been recently published with some disadvantages involved, including large skin incisions and donor site morbidity. Arthroscopic stabilizing techniques carry the potential of inadequate restoration of MPFL function. We present a minimally invasive technique for MPFL reconstruction using adductor magnus tendon autograft. This technique is easily performed, safe, and provides a stabilizing effect equal to current MPFL reconstructions. Skin incision of only 3-4 cm is located at the level of the proximal half of the patella. After identifying the distal insertion of the adductor magnus tendon, a tendon harvester is introduced to harvest the medial two-thirds of the tendon, while the distal insertion is left intact. The adductor magnus tendon is cut at 12-14 cm from its distal insertion and transferred into the patellar medial margin. Two suture anchors are inserted through the same incision at the superomedial aspect of the patella in the anatomic MPFL origin. The graft is tightened at 30 degrees knee flexion. Aftercare includes 4 weeks of brace treatment with restricted range of motion.

The purpose of this study was to evaluate the reoperation rate of elbow synovectomy in patients with rheumatoid arthritis. A total of 103 synovectomies were performed in 88 patients (61 women) with rheumatoid factor–positive rheumatoid arthritis with a mean follow-up of 5.2 years (range, 1-8 years). The survival rate after elbow synovectomy (free from reoperation) was 77% (95% confidence interval, 66%-85%) at 5 years. Eight resynovectomies and fourteen total elbow replacements were performed during the follow-up. No significant improvement in range of motion was detected after synovectomy, but pain relief and patient satisfaction were favorable. Elbows were classified preoperatively (before primary synovectomy) with the Larsen system. All resynovectomies were performed for elbows of grade 0-2 destruction. A significant difference was found between early (Larsen grade 0-2) and late (Larsen grade 3) synovectomies in relation to elbow replacement ( P = .002) during the follow-up. Late synovectomy yielded more temporary pain relief with a high rate of elbow arthroplasties.

Twenty-four primary elbow synovectomies were done between 1991 and 1998 at the authors' institution on 19 patients (15 females, four males) with juvenile rheumatoid arthritis. Five bilateral and 14 unilateral procedures were done. The mean age of the patients was 29 years (range, 11-64 years) at the time of surgery and the mean disease duration was 19 years (range, 2-51 years). Preoperatively radiographic destruction of Larsen Grade 1 was detected in 21% of elbows, Grade 2 in 54%, and Grade 3 in 4%. In 21% of elbows no radiographic destruction was present (Grade 0). The cumulative survival rate of elbow synovectomy was 84% (95% confidence interval, 68-98) at 5 years. Four resynovectomies and two elbow replacement arthroplasties were done during the followup period. Complete pain relief was documented in 44% of patients and subjective outcome was excellent or good in 72% of patients. No significant improvement was observed in functional ability or range of motion in extension and flexion or pronation and supination. The results of the current study (mean followup, 5 years; range, 2-9 years) are slightly worse compared with the short-term results of elbow synovectomy in patients with adult-onset rheumatoid arthritis.

Between 1990 and 1996, 119 Finnish male conscripts underwent operative treatment for patellar dislocation. There were 68 conscripts (58%) with primary and 51 conscripts (42%) with recurrent patellar dislocation. Sixty-five (55%) dislocations occurred during military service, 40 (34%) occurred during sports activities, and 14 (11%) occurred during leisure time. The most common cause of injury was military training at battle exercises (n = 30). The typical injury mechanism was knee valgus rotation on fixed foot and tibia (97 conscripts, 82%). Surgical procedures performed were open in 75 conscripts (63%) and arthroscopically assisted in 44 conscripts (37%). Twenty-three (19%) redislocations occurred during follow-up (mean, 6 years; range, 3-9 years). The subjective outcome of treatment was excellent in 23 (19%), good in 42 (35%), moderate in 44 (37%), and poor in 10 (9%) conscripts. The most common residual complaint was patellofemoral pain (25 conscripts, 21%). Only 42 (35%) conscripts were able to finish their military service normally; fitness classification was decreased in 16 conscripts (13%), and 61 (52%) were temporarily exempted from military service (class E). The results of operative treatment did not differ significantly in conscripts with primary and recurrent dislocation, except for the time of first recurrence, which was significantly longer in conscripts with primary than with recurrent dislocation (27 versus 9 months). Patellar dislocation is the most common form of severe knee injury among conscripts and significantly hampers military service. Operative treatment yields only satisfactory results. Preventive measurements should be considered. A suggested algorithm for the treatment and classification of acute and recurrent patellar dislocation among military conscripts is presented.

A cohort of 74 patients with rheumatoid arthritis (RA) was followed prospectively for 15 years. At the end of the study, 148 elbows were radiographed with standard methods. The bone destruction of the humerus was measured from the anteroposterior (AP) radiograph as the bone attrition of the trochlea (TM) and the capitellum (CM). The bone destruction of the ulna was measured from the AP radiograph as the width (WO) and from the lateral radiograph as the thickness (TO) of the olecranon. Moreover, elbow joint destruction was graded by the Larsen system on a scale of 0 to 5. The relation of bone destruction to Larsen grade of the elbows was examined. The mean TM of the nonaffected (Larsen grades 0 to 1, n = 73) joints was 17.5 mm (SD, 2.1 mm; range, 10-22 mm), whereas the mean of Larsen grade 3 to 5 joints (n = 26) was 11.5 mm (SD, 5.2 mm). The mean CM of the nonaffected joints was 19.6 mm (SD, 2.6 mm; range, 15-25 mm), and the corresponding mean of Larsen grade 3 to 5 joints 15.5 mm (SD, 4.5 mm). The mean TO of the nonaffected joints was 18.9 mm (SD, 1.5 mm; range, 17-23 mm), and the mean of Larsen grade 3 to 5 joints was 13.9 mm (SD, 4.1 mm). The mean WO of the nonaffected joints was 23.3 (SD, 2.4 mm; range, 18-28 mm), and the mean of Larsen grade 3 to 5 joints was 22.4 mm (SD, 6.2 mm). Spearman correlation coefficients between TM, CM, and TO and Larsen grade of the joint were -0.45 (95% CI, -0.31 to -0.57), -0.38 (95% CI, -0.23 to -0.51), and -0.46 (95% CI, -0.31 to -0.57), respectively. Bone destruction in both the humerus and the olecranon appears to be a late consequence of rheumatoid elbow involvement. Bone loss is always present in the situation of rheumatoid elbow replacement, and it is most remarkable in Larsen grade 5 joints; the risk of preoperative and intraoperative complications due to bone destruction is significantly increased in this group.

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors’ institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0–5° of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Eighty-two patients (50 women, 32 men) underwent isokinetic muscle testing on average 13 years after a conservatively treated unilateral primary patellar dislocation. Three study groups were formed according to the natural history of recovery: group A (n = 32), patients with only primary conservative treatment; group B (n = 34) patients with conservative (group B1; n = 24) or surgical (group B2; n = 10) treatment of redislocations; group C (n = 16) patients with other residual complaints (anterior knee, pain subluxations) requiring surgery. The Cybex 6000 dynamometer system was used as the testing machine for quadriceps and hamstrings muscles, with proportional deficits of peak torque as the test parameter. Isokinetic testing revealed both quadriceps and hamstring muscle atrophy even after long-term recovery from injury. There were statistically significant differences between the three study groups at both tested speeds of quadriceps muscles (60 rad/s, P < 0.002; 180 rad/s, P < 0.009). Groups B1 and B2 presented similar results. The muscle performance findings are probably due to more than one factor: primary immobilization, poor outcome, patellofemoral degeneration, redislocations, and residual knee complaints followed by surgery and deficiency in motor control of thigh muscle had--together or separately--an effect on muscle performance.

75 patients had closed treatment for a primary unilateral acute patellar dislocation. All patients were studied clinically, radiographically and for isokinetic thigh muscle performance a median of 11 (6-24) years later. During the follow-up, 37 patients had experienced recurrent dislocations. The functional outcomes were similar in patients with or without recurrence. Radiographically unstable patellar morphology, spontaneous reduction of the dislocation and low volume of hemarthrosis predisposed to recurrence.

Clinical and radiographic studies were done for 85 patients treated conservatively for acute primary patellar dislocation occurring an average 13 years (range, 6-26 years) previously. Osteoarthritic changes in the patellofemoral joint were evaluated with special reference to the primary conservative treatment and treatment of redislocations (operative or conservative) or treatment for other subsequent problems such as pain and/or subluxations (late surgery). The patients were divided into two groups on the basis of findings in the unaffected knee and other joints. There were 56 patients (66%) with predisposing factors such as an abnormal quadriceps angle, positive apprehension test, quadriceps muscle atrophy, or generalized joint laxity common to all patients. Patients with or without predisposing factors did not differ from each other in terms of arthritic changes. Patellofemoral joint degeneration was found in the affected knee in 19 patients (22%) and in the unaffected knee in nine (11%). Conservative treatment without subsequent redislocations resulted in osteoarthritic changes in 29% of the cases and in 13% of cases with occasional redislocations. Osteoarthritic changes were found in 17% of patients treated operatively and in 12% of patients treated conservatively for redislocations. Of the patients who underwent late surgery for patellofemoral pain or subluxations, 35% showed osteoarthritic changes. In general, there were more degenerative changes in patients with stable patellae (no redislocations) than in those with occasional recurrences, especially in older and heavier patients.

To the Editor: I read with interest the paper by Sillanpaa et al. [1] entitled “Ligament Reconstruction Versus Distal Realignment for Patellar Dislocation” published in the June 2008 issue. I congratulate the authors on their study, for the long-term followup and for the comparative study with distal realignment. However, I ask for clarification of two issues. First, what are the indications for medial patellofemoral ligament reconstruction? Do you perform this surgical technique in all patients with patellar recurrent dislocation? Soft tissue abnormalities, such as lateral retinacular tightness, and some bony geometric knee parameters, such as the tibial tubercle-trochlear groove distance, patella alta, and trochlea dysplasia, can cause patellofemoral instability. Do you combine additional surgical procedures, such as a distal realignment and/or lateral retinacular release, when you find an abnormal Q angle (> 10°), or a great tibial tubercle-trochlear groove distance (> 20 mm), or a flattened trochlea? Trochlea dysplasia is thought to lead to excessive load on the medial patellofemoral ligament reconstruction, and tibial tuberosity transfer would, in theory, reduce the load to the reconstruction. Second, I believe a surgical technique can prevent degenerative changes when it improves patellofemoral tracking and corrects some abnormal geometric parameters, such as congruence angle or lateral patellofemoral angle. Have you assessed postoperatively by radiographs or MRI whether the ligament reconstruction was able to correct the above-mentioned parameters, in comparison to the contralateral knee?