Search

Medial dislocation of patella has been commonly reported as a complication of the surgical release of the lateral patella-femoral ligament. A traumatic medial eversion-dislocation of the patella has not been earlier reported. We report an unusual case of traumatic medial patellar eversion-dislocation in a young adult patient whose MRI showed a discontinuity in medial and lateral patellar retinacula. However, intraoperatively the retinacula were found intact and relocation of the patella was achieved by flipping the patella through a small hole in the patellar tendon. No reconstruction of the ligaments was needed. At 1-year follow-up, the patient achieved full range of movements of the knee and there were no subjective complaints of instability. In our case, although the patella was medially everted and dislocated, both the retinacula were still intact. Clinicians should be aware that acute traumatic patella medial dislocation and eversion can occur without disruption of the medial or lateral retinaculum. Furthermore, knee MRI may suggest patellar retinacula disruption due to the retinaculum's obscure and tortuous course in patients with these injuries.

The lateral patellofemoral complex is an important stabilizer to medial and lateral displacement of the patella. Soft tissue abnormalities can range from pathologic tightness to laxity, presenting with symptoms related to patellar instability, anterior knee pain, or arthritis. Clinical evaluation should be performed to confirm patellar dislocation, assess the integrity of the lateral and medial soft tissues, and explore other pathoanatomic factors that may need to be addressed. Lateral retinacular lengthening is recommended over lateral release owing to the potential of iatrogenic medial instability with release, and a lateral patellofemoral ligament reconstruction can be performed to effectively treat medial instability.

Purpose Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature analysed clinical results after regenerative cartilage repair of the patella with a special focus on the assessment and treatment of existing patellofemoral malalignment. Methods A systematic review was conducted to identify articles reporting clinical results after cartilage regenerative surgeries of the patella using the PubMed and Scopus database. The extracted data included patient-reported outcome measures (PROMS) and whether cartilage repair was performed alone or in combination with concomitant surgeries of underlying patellofemoral co-pathologies. In cases of isolated cartilage repair, specific exclusion criteria regarding underlying co-pathologies were screened. In cases of concomitant surgeries, the type of surgeries and their specific indications were extracted. Results A total of 35 original articles were included out of which 27 (77%) were cohort studies with level IV evidence. The most frequently used technique for cartilage restoration of the patella was autologous chondrocyte implantation (ACI). Results after isolated cartilage repair alone were reported by 15 (43%) studies. Of those studies, 9 (60%) excluded patients with underlying patellofemoral malalignment a priori and 6 (40%) did not analyse underlying co-pathologies at all. Among the studies including combined surgeries, the most frequently reported concomitant procedures were release of the lateral retinaculum, reconstruction of the medial patellofemoral ligament (MPFL), and osteotomy of the tibial tubercle. In summary, these studies showed lower preoperative PROMS but similar final PROMS in comparison with the studies reporting on isolated cartilage repair. The most frequently used PROMS were the IKDC-, Lysholm- and the Modified Cincinnati Score. Conclusion This comprehensive literature review demonstrated good clinical outcomes after patellar cartilage repair with no evidence of minor results even in complex cases with the need for additional patellofemoral realignment procedures. However, a meaningful statistical comparison between isolated patellar cartilage repair and combined co-procedures is not possible due to very heterogeneous patient cohorts and a lack of analysis of specific subgroups in recent literature. Level of evidence Level IV.

The lateral retinaculum is a 2-layered structure. The plane between the superficial oblique fibers and the deep transverse fibers allows for coronal plane Z-lengthening of the lateral retinaculum. The lengthening procedure can be used for treatment of lateral patellar hypercompression syndrome or as an adjunct to surgical procedures undertaken to address patellar instability. This article describes the surgical technique for lateral retinacular lengthening. Level 1 Knee. Level 2 Malalignment, patellofemoral, other., Technique Video Video 1 Animations plus live demonstration of a right knee lateral patella retinaculum Z-lengthening release, with narration of objectives, principles, steps, and emphasis of key surgical points.

There are certain risk factors responsible for patella instability that should be identified before choosing the most appropriate treatment. We evaluated 83 skeletally immature patients who, after two or more patellar dislocation episodes, underwent surgical treatment to address the condition of patellar instability. Each patient was evaluated for patellar instability risk factors using the Balcarek patellar instability severity score. Evaluation of patellar instability included knee MRI to systematically identify anatomical risk factors. The preoperative and postoperative clinical evaluation included the modified Cincinnati score and the Kujala score. The Roux-Goldthwait technique combined with lateral retinaculum release and the advancement of the vastus medialis oblique (VMO) was performed on all knees. The mean patient age at the time of surgery was 12.2 ± 1.59 years (range 8–14 years). The average follow-up was 4.72 ± 1.37 (range 3–8) years. Trochlear dysplasia (decreased trochlear depth), the most common anatomical risk factor, was identified in 71 knees (83.5%). The modified Cincinnati score increased from 58.46 ± 8.75 (range 49–76) points to 94.07 ± 2.88 (range 88–98) postoperatively. The mean Kujala scores increased from 58.51 ± 8.94 (range 49–76) points to 93.66 ± 2.65 (range 87–98) postoperatively. The two-tailed P value was less than 0.0001. The patients were followed until their skeletal maturation, without reporting any incidents of patella dislocation, except one. The Roux-Goldthwait technique combined with lateral retinaculum release, and the advancement of VMO, can restore patellar tracking and can decrease the probability of another dislocation. It was an effective treatment in skeletally immature patients who had two or more episodes of patellar dislocation. IV.

IntroductionThe role of the lateral retinaculum in patellofemoral instability is still debated. Lateral retinacular release (LRR), has been extensively performed in combination with different surgical procedures, including reconstruction of medio-patellofemoral ligament (MPFL). Despite controversial indications, the results from these studies seem promising. The present study conducts a systematic review about current biomechanical and clinical evidence concerning the role of LRR in combination with MPFL reconstruction. We performed a comprehensive literature research, comparing the outcomes of MPFL reconstruction with and without LRR.Materials and methodsThis systematic review was conducted according to the PRISMA guidelines. The literature search was performed in August 2020. All articles describing the outcome of isolated MPFL reconstruction alone or in combination with a LRR in patients with recurrent patellofemoral instability were considered for inclusion. Only articles reporting data on patients with a minimum of 12-month follow-up were included. Only articles reporting quantitative data under the outcomes of interest were included.ResultsA total of 63 articles were eligible for this systematic review, including 2131 knees. The mean follow-up was 40.87 ± 24.1 months. All scores of interests improved in favour of the combined group: Kujala + 3.8% (P = 0.01), Lysholm + 4.2% (P = 0.004), Tegner + 0.8 points (P = 0.04), IKDC + 9.8% (P = 0.02). The ROM was comparable between the two groups (P = 0.4). Similarity was found in terms of positivity to the apprehension test (P = 0.05), rate of complications (P = 0.1), re-dislocations (P = 0.8), and revision surgeries (P = 0.1).ConclusionThere is no evidence that adding a lateral release impacts positively on the outcome of MPFL reconstruction.Level of evidence: IV, Systematic review

Relevance. The patellar fractures are relatively rare. Their clinical significance is associated with the fact that they can cause the development of severe patellofemoral pain syndrome. Lateral retinaculum release was introduced into clinical practice in 1970s for treating this syndrome and since was widely used. The biomechanical validity of this operation has been proven experimentally, but the role of lateral release in the prevention of patellofemoral arthritis progression and concomitant pain after patellar fractures remains poorly understood. The purpose of the study was to improve the results of the patellar fractures surgery by combining osteosynthesis with lateral retinaculum release. Materials and Methods. This was a non-randomized, cohort, open-label prospective study with retrospective control. The treatment results of the patients with closed patellar fractures were analyzed. The prospective group (n = 45) was formed sequentially during 2018–2019. The retrospective control group (n = 41) was selected from the database of the city center of traumatology according to the inclusion criteria. The difference between both group was that in the patients of the prospective group, open osteosynthesis of the patella with wire segments and a stretching wire loop was combined with minimally invasive release of the lateral retinaculum. The function of the operated knee joint was assessed in 12 months after the surgery by the KOOS. The magnitude of the patellar articular surface discongruence was measured by x-rays; the stage of patellofemoral arthritis was classified by Iwano. The statistical analysis included the calculation of medians, means, absence/presence differences in groups indicators, correlation analysis of the measured variables. Results. The comparing groups were heterogeneous in gender, age, and types of fractures: the prospective group comprised 18 women (49.7±14.7 years), 27 men (45.1±11.2 years), the retrospective 13 women (50.2±12.3 years), 28 men (41.9±10.7 years). In the prospective group, compared with retrospective, the 34-C1, 34-C2 fractures were prevailed. The null hypothesis about the equality of KOOS indicators and the stage of patellofemoral arthritis in both groups was rejected at the p0.05 significance level. The patients of the prospective group had better KOOS indicators. The Spearman’s correlation analysis revealed a positive relationship between KOOS scores in the range 0.26 to 0.41 and a negative correlation between the stage of arthritis (-0.29) and lateral release. Conclusion. Testing the null hypothesis that there was no difference between the KOOS scores between the prospective and control groups confirmed its inconsistency. The beneficial effect of lateral release on the knee function was demonstrated in the mid-term results of the patellar fractures osteosynthesis.

The main aim of this article was to examine the therapeutic evaluation of our modified partial lateral facetectomy of the patella for stage III lateral patellofemoral osteoarthritis (PFOA), which includes (1) partial lateral patella articular facet that was resected; (2) coronal Z-shaped incision to lengthen lateral retinaculum; (3) patellar perimeter electrocoagulation to denervate. Between December 2008 and January 2013, 36 knees of 32 patients with severe patellofemoral (PF) osteoarthritis (OA) were treated with our modified partial patellar lateral facetectomy. All patients were stage III according to the Iwano scale, and their patellas were all Wiberg type III or Baumgartl type IV in shape. The study group included 6 males and 26 females with an average age of 54.03 years and an average disease course of 8.67 years. The modified Kujala scores were used to evaluate PF function, and the congruence angle was used to evaluate the patellar position. Knee Society Scores (KSS) were used to evaluate overall knee function. Six knees of five cases were lost to follow-up. Thirty knees of 27 cases were followed up for 5 years, with an average follow-up time of 60 ± 3.2 months. The average preoperative modified Kujala score was 15.93, and the average score at last follow-up was 32.03; The satisfactory PF function was achieved in 28 knees (93.33%). The congruence angle improved from preoperative +23. 07 degrees to 11. 91 degrees at the last follow-up. The average preoperative KSS were 110.40 points, which increased to 156.77 points at the last postoperative follow-up. Pain was significantly relieved, and the ability to climb stairs was significantly improved. All scores showed statistically significant improvements after surgery (p

Objective To describe the surgical reduction of luxation of the triceps brachii tendon in a dog. Animal One 2.5-year-old 2.58 kg castrated male toy poodle. Study design Clinical case report. Methods The dog displayed intermittent, non-weight bearing lameness of the right forelimb for approximately 18 months before presenting at the veterinary medical center. Medial subluxation of the right elbow joint was detected by palpation. The Campbell test was consistent with an increased range of motion during supination. At ultrasonographic examination, medial luxation of the triceps brachii tendon was noted, whereas collateral ligaments appeared normal. No skeletal deformities were found on radiographs of the right forelimb. The luxation of the triceps brachii tendon was surgically corrected with antirotational suture, a stopper pin, medial retinaculum release, and imbrication of the lateral retinaculum. Results The right triceps brachii tendon and elbow joint were successfully reduced. Gait returned to normal by 55 days postoperatively. No implant failure or recurrence were observed 3.5 years after surgery. Conclusion Surgical reduction of a luxation of the triceps brachii tendon in a dog resolved lameness and restored the range of motion of the affected elbow, leading to good long-term outcome.

Case Combined medial and lateral patellar instability is exceptionally rare with only 3 reported cases to date. Here, we present the case of a 37-year-old White woman with multiple recurrent medial and lateral patellar instability. After failure of conservative care with bracing and therapy, she underwent surgical stabilization with medial and lateral allograft reconstruction. Conclusion This case provides an example of the condition and successful surgical follow-up.

The infrapatellar fat pad (IPFP), located in the anterior compartment of the knee, is frequently a source of pain for athletes in sports involving terminal extension of the knee. Most often, impingement of the IPFP between the femur and the tibia is the source of pain; however, other pathology is possible. Hemangiomas, synovial cysts, and synovial sarcomas have been observed in the pediatric population. IPFP herniation through the lateral retinaculum has been described, as well.

The study focused on the application value of Algebraic Reconstruction Techniques (ART) based magnetic resonance imaging (MRI) in the diagnosis of cartilage injury in patients with patellar dislocation, as well as the treatment effect of platelet-rich plasma (PRP). 50 patients with patellar dislocation admitted to the hospital were selected as the research subjects, and they were randomly divided into the experimental group (lateral retinaculum plasty and PRP treatment) and the control group (lateral retinaculum plasty), with 25 cases in each group. The ART-based MRI technology was used to judge the recovery of patients after surgery and analyze the differences in clinical data between the two groups. The results showed that the running speed under ART algorithm was significantly faster than the traditional Joseph algorithm and Siddon algorithm, and the image reconstruction effect was better. The visual analog scale (VAS) scores of preoperative and postoperative pain and the Hospital for Special Surgery (HSS) score in the experimental group were better than those of the control group ( P < 0.05 ). In conclusion, the ART-based MRI technology can clearly show cartilage injury and the PRP treatment can effectively relieve postoperative pain, with reliable curative effects and simple operations.

The anterolateral ligament (ALL) has been distinctly characterized in the human knee, so there has been a resulting search for animal models with this ligament. Sus scrofa domestica, the domestic pig, has many biomechanical qualities similar to those of human knees, so this study searched for incidence of the ALL in 10 separate specimen knees. The anatomic dissection yielded no identification of an ALL structure in any of the specimens examined. However, the knees did possess other identifiable structures on the anterolateral aspect of the knee, including the lateral collateral ligament (LCL), tibialis anterior tendon (TAT), and lateral retinaculum (LR). These were harvested and tested to determine if their biomechanical properties compensated for the lack of the ALL. The TAT had the largest average Young's modulus, followed by the LCL, and then the LR. The LR had the longest average end of toe region, followed by the TAT, and then the LCL. The properties of these anterolateral structures, the lifestyle, and the evolutionary path of S. scrofa likely offer insight as to why this species might lack an ALL. This study concludes that S. scrofa does not serve as an animal study model for the anterolateral ligament.

Povećana napetost lateralnog retinakula patele može se javiti kao samostalni entitet ili u sklopu drugih poremećaja patelofemoralnog zgloba kao što su patelofemoralna displazija, lateralna nestabilnost patele, ozljede medijalnog patelofemoralnog ligamenta i hondromalacija. Presijecanje lateralnog retinakula, kako bi se postigao bolji balans aktivnih i pasivnih stabilizatora patele i na taj način korigirao njen položaj, bila je jedna od najizvođenijih operacija u ortopediji bez obzira na etiologiju poremećaja. Biomehaničke i kliničke analize pokazale su mogućnost nastanka brojnih komplikacija koje mogu nastati neselektivnom primjenom ove operacijske tehnike od kojih je najteža medijalna nestabilnost patele. Danas se kao metoda za korigiranje napetosti lateralnih stabilizatora patele češće upotrebljava tehnika produljivanja lateralnog retinakula kojom se puno bolje može regulirati napetost lateralnih struktura uz značajno manje komplikacija., Tightness of the lateral patellar soft tissue complex could be isolated entity or associated with other patellofemoral disorders such as patellofemoral dysplasia, lateral patella instability, medial patellofemoral ligament injury and chondromalatia. Lateral retinacular release was a method of choice among orthopaedic surgeons for improving the patellofemoral balance and congruency regardless the etiology of patellofemoral disorders. Biomechanical and clinical studies have shown that nonselective use of this surgical method could cause numerous complications among which medial patellar instability is the worst. Today most orthopaedic surgeons prefer lengthening instead release, because lateral lengthening is a more precise technique, with reduced complication rates.

Patellar lateral retinaculum release represent an useful procedure and a relatively frequent treatment performed in knee surgery. Indication to patellar lateral retinaculum release, both as an isolated procedure or associated with other techniques, include different disorders of the extensor mechanism, such as acute or chronic patellar instability, anterior knee pain, patellofemoral condropathies or osteoarthritis. This study aimed to analize the indications and clinical effectiveness of patellar lateral retinaculum reslease through a review of the most relevant literature.

OBJECTIVES To measure the medial and lateral retinaculum thickness in individuals with and without patellofemoral pain using ultrasound and to assess associations with the symptom duration and function. METHODS Medial and lateral patellofemoral joint retinaculum thicknesses of 32 knees (16 with patellofemoral pain and 16 asymptomatic) were measured with B-mode ultrasound at 0.5, 1, and 1.5 cm from the patella border. Participants with patellofemoral pain completed a Kujala questionnaire, and both groups underwent a single-leg squat performance assessment. Two-way analyses of variance (site × group) determined the overall effect, and Cohen d values were calculated to describe the magnitude of the difference for each measurement. RESULTS The groups were matched for age, height, and weight. Compared to controls, participants with patellofemoral pain had thicker lateral (overall effect, P = .03) and medial (overall effect, P

Case We present an 18-year-old man with poor alignment of the lower limbs, marked by congenital dislocation of the left patella, with gait impairment, and an associated 20° flexion contracture. Surgical treatment was performed with a single complex procedure with the release of the lateral retinaculum, capsule, and iliotibial tract, followed by a subtraction trochleoplasty, tibial tubercle transfer, elongation of the quadriceps tendon, and anatomical reconstruction of the medial patellofemoral ligament. At the 5-year follow-up, the patient had a significant improvement in gait pattern, with the patella centered on the new trochlear groove without any signs of patellar instability. Conclusions The approach of congenital dislocation of the patella is controversial, and although numerous procedures have been described in children, the approach in adults should be individually tailored. In this case, trochlear deepening and preserving the trochlear cartilage proved to be an effective option for treating a congenital dislocation.

To elucidate the outcomes of lateral retinaculum plasty versus lateral retinacular release with concomitant medial patellofemoral ligament (MPFL) reconstruction. In a prospective study, 59 patients treated at our institution from 2012 to 2014 were included. The 59 patients were randomly divided into two groups. Group I included 27 patients who underwent lateral retinacular release and MPFL reconstruction. Group II included 32 patients who underwent lateral retinaculum plasty and MPFL reconstruction. All patients were followed up for at least 2 years and all assessments were performed both pre- and post-operation. Clinical evaluation consisted of the Kujala score, patellar medial glide test, and patellar tilt angle, patellar lateral shift, and congruence angle, measured on CT scan. Significant improvement was seen after surgery in both groups. The group of lateral retinaculum plasty achieved better results than the group of lateral retinacular release. No statistically significant differences were found in lateral patellar shift (ns) or congruence angle (ns) between the groups. There were significant differences in Kujala score (P

To evaluate the clinical outcomes of double-bundle anatomical medial patellofemoral ligament (MPFL) reconstruction combined with lateral retinaculum plasty versus isolated MPFL reconstruction for patellar dislocation. From 2011 to 2013, 64 patients underwent either double-bundle anatomical MPFL reconstruction combined with lateral retinaculum plasty (Group A, 32 patients), or isolated MPFL reconstruction (Group B, 32 patients). Clinical evaluations were performed 2 years post-operatively and included determination of the number of patients with patellar redislocation, the patellar tilt angle, lateral patellar shift, subjective symptoms, and functional outcomes as evaluated with the Kujala score and Lysholm score. No dislocation or subluxation occurred during the 25-month follow-up. Radiographically, the patellar tilt angle was 6.0° ± 1.7° in Group A and 6.7° ± 2.0° in Group B, without a significant difference (n. s). The lateral patellar shift was 8.0 ± 2.6 mm in Group A and 8.5 ± 2.4 mm in Group B (n. s). The mean Kujala score was 91.8 ± 3.7 in Group A and 91.5 ± 3.6 in Group B post-operatively (n. s), and the mean Lysholm score was 92.5 ± 3.8 and 90.8 ± 4.9, respectively (n. s). Double-bundle anatomical MPFL reconstruction with lateral retinaculum plasty is a promising procedure that provides a new option for patellar dislocation. III.

Background Periarticular injections have become a valuable adjunct to multimodal pain control regimens after knee and hip arthroplasties. Injection techniques vary greatly among surgeons with little standardization of practice. Methods We performed an extensive literature search to determine where nociceptive pain fibers are located in the hip and the knee and also to explore the pharmacology of periarticular cocktail ingredients. Results Large concentrations of nociceptors are present throughout the various tissues of the knee joint with elevated concentrations in the infrapatellar fat pad, fibrous capsule, ligament insertions, periosteum, subchondral bone, and lateral retinaculum. Less empiric evidence is available on nociceptor locations in the hip joint, but they are known to be located diffusely throughout the hip capsule with elevated concentrations at the labral base and central ligamentum teres. Local anesthetics are the base ingredient in most injection cocktails and function by blocking voltage-gated sodium channels. Liposomal anesthetics may offer longer duration of action over traditional anesthetics. Nonsteroidal anti-inflammatory agents and corticosteroids block peripheral production of inflammatory mediators and may desensitize nociceptors. Opioid receptors are present in lower densities peripherally as compared with the central nervous system, but their inclusion in injections can lead to pain relief. Sympathetic drugs can provide adjunct effects to periarticular cocktails to increase duration of action and effectiveness of medications. Conclusion Targeting specific sites of nociceptors may help to further decrease pain after knee and hip arthroplasties. Altering periarticular cocktail ingredients may aid in multimodal pain control with injections.

Most cases of medial patella subluxation occur under iatrogenic conditions that are often associated with a prior excessive lateral retinacular release procedure. We report a case of medial subluxation following minor trauma with no history of previous lateral release. The abnormality was identified on magnetic resonance imaging and was successfully treated by direct repair of the lateral retinaculum. The recognition and treatment of medial subluxation of the patella without retinacular release can be difficult. Therefore, consideration of multiple causes through careful medical history taking, physical examination, and radiologic examination is needed for accurate diagnosis.

We present a case of osteonecrosis of bipartite patella occurring after total knee arthroplasty using medial parapatellar approach without lateral retinacular release in osteoarthritic knee of a 66 year-old-male. The surgery was performed using traditional technique with medial parapatellar approach and patella was resurfaced. Patella was everted during surgery. There was no event during follow-up period after surgery. Range of motion of the knee was 135° without flexion contracture. Eight months after the surgery, patella was fragmented and resorbed on the radiographs which was consistent with osteonecrosis. The patient showed extension limitation of 30° with no pain. Patellar osteonecrosis has been rarely reported after total knee arthroplasty with lateral retinacular release. However, there was no report of patellar osteonecrosis after total knee arthroplasty without lateral retinacular release. Caution should be taken about patellar osteonecrosis in case of bipartite patella even though lateral retinaculum is preserved during total knee arthroplasty. Keywords: Knee, Patella, Total knee arthroplasty, Osteonecrosis, Bipartite patella

Lateral patellofemoral (PF) soft tissue abnormalities range from excessive lateral PF tightness (lateral patellar compression syndrome, lateral patellar instability and arthritis), to excessive laxity (iatrogenic lateral PF soft tissue insufficiency postlateral release). The lateral soft tissue complex is composed of the iliotibial band extension to the patella, the vastus lateralis tendon, the lateral PF ligament, lateral patellotibial ligament, and lateral patellomeniscal ligament, with intimate connections between those structures. To identify lateral retinaculum tightness or insufficiency the most important tests are the patellar glide test and patellar tilt test. Imaging aids in that evaluation relying mostly on the patella position assessed by radiographs, computed tomography, and magnetic resonance imaging with referencing to the posterior femoral condyles. Lateral retinaculum lengthening (preferred) or release may be added when there is excessive lateral retinaculum tightness. A lengthening may be performed using a minimally invasive approach without compromising the lateral patella restraint. Lateral retinaculum repair or reconstruction is indicated when there is lateral retinaculum insufficiency. Lateral retinaculum surgery to balance the medial/lateral soft tissue restraints, improves patellar positioning and clinical results.

The patellofemoral joint is often affected by torsionaldisorders of the lower limb, causing pain, instability and knee degeneration. The aims of this study were to determine functional outcomes of patients who underwent a high tibial derotation osteotomy (HTDO) for symptomatic squinting patella due to increased external tibial torsion. Moreover, factors associated with inferior clinical outcomes were investigated.Patients with symptomatic squinting patella, increased external tibial torsion (30°) treated with this technique, and with 2 years of follow up were included. Fulkerson and Kujala patellofemoral joint scores were assessed. Age, body mass index, history of prior surgery, increased femoral anteversion, association of lateral retinaculum release and patellar cartilage lesions were analysed.Sixty HTDOs were included in this retrospective study with an average of 66 months of follow up. The mean Kujala score improved from 47.5 preoperatively to 93 postoperatively. The mean Fulkerson score improved from 40.6 to 91.6. Kujala subscores for pain improved from 8.6 to 30.4, for instability improved from 6.4 to 17.9, and their ability to climb stairs increased from 6.9 to 17.9 (all P 0.0001). Multivariate logistic regression model identified that patient age (P 0.005) and advanced chondral damage (P 0.001) were the dominant factors predicting inferior clinical outcomes using Kujala's score.HTDO provided good results regarding the pain symptoms, instability and the ability to climb stairs. Advanced chondral damage and advanced age had negative effects on outcomes.

Purpose: To determine the biomechanical effect of limited lateral retinacular and capsular release on lateral patellar translation as a function of constant force at various knee flexion angles. Methods: Six pairs of bilateral cadaveric knee specimens (12 knees) were obtained from a tissue bank, dissected, and potted in a perfect lateral position based on fluoroscopy. A direct lateral force was applied to the patella through an eye screw in the midpoint of the lateral patella, and each knee underwent testing in the intact state and after lateral retinacular and capsular release. All knees were tested at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of flexion using a custom-machined jig on a materials testing system with a 20-N lateral force applied to the patella. Patellar displacement was recorded and compared for each specimen. Results: Lateral displacement was significantly greater at all degrees of flexion for the lateral-release specimens than for an intact lateral retinaculum (P < .05). Compared with intact specimens, lateral-release specimens experienced 30% more translation at 0° of flexion and between 6% and 9% more lateral translation at 10° to 90° of flexion. Conclusions: Lateral retinacular and capsular release results in significantly increased lateral patellar translation at all flexion angles compared with intact specimens. This finding suggests that the lateral retinaculum may function as a significant restraint to lateral translation even with intact medial soft-tissue restraints. Clinical Relevance: Arthroscopic and open limited lateral retinacular releases should be performed with extreme caution when treating lateral patellar instability given the lateral retinaculum’s apparent role as a secondary restraint.

Background In previous reports of lateral canthoplasty, the components of the inferior retinaculum were mostly secured to the lateral orbital rim at a level around the pupil or superior limbus. However, that level is not adjustable in young patients who want to lengthen the short palpebral fissure for cosmetic purposes. Moreover, the anchoring method based on the palpebral portion can also be inconvenient and ineffective. Thus, the authors report an effective fixation level of the lateral orbital rim to lengthen and widen the lateral palpebral fissure. Methods From June 2015 to August 2017, 202 women and 44 men underwent cosmetic lateral canthoplasty (mean age 28.4 ± 2.8 years old). The lower lid component of the lateral retinaculum was identified and selectively released through a small incision at the lateral commissure. Then, the released retinaculum was secured to the periosteum of the inner aspect of the lateral orbital wall. The fixation level corresponded to the most concave portion or immediately below the most concave point (1 to 2 mm below). Results Cosmetic lateral canthoplasty was successfully performed in all cases. No severe complications were observed. There were some minor complications. In most cases, the lateral palpebral fissure was naturally reshaped into a wider and brighter contour. Almost all of the patients were satisfied with the results of the treatment. Conclusions The anchoring procedure at the most concave portion of the lateral orbital rim, which corresponds to the level of the inferior edge of the limbus or medial epicanthus, consistently resulted in a brighter and wider shape of the lateral palpebral fissure. Fixation based on the bony portion, compared to palpebral portion, offers several advantages as follows: effective lengthening and widening the lateral palpebral fissure; ease of application; symmetry with consistent final results; and minimal occurrences of overcorrection and undercorrection.

Background Improved knowledge of the distal triceps insertion is needed as a result of an increase in procedures involving this area, including distal triceps repair, posterior capsulectomy, and olecranon tip osteotomy for coronoid reconstruction. Materials and methods Five pair-matched upper limbs were dissected to study the morphology and dimension of the distal triceps tendon, triceps tendon insertion, capsular insertion on the olecranon, and triceps lateral retinaculum. Muscle origins of the triceps insertions were identified proximally. Results Three distinct insertional areas were found in the olecranon corresponding to the posterior capsular insertion, the deep muscular portion, and the superficial tendinous portion of the triceps with areas of 1.5, 1.2, and 2.8 cm 2 , respectively. The deep muscular head corresponded to the medial head of the triceps and the tendinous portion corresponded to the long and lateral heads and correlated with the height of the specimen. The triceps width at insertion was 2.6 ± 0.5 cm (standard deviation), and the triceps lateral retinaculum extended the tendon laterally for 2.5 ± 0.7 cm. The tendinous portion of the triceps tendon extended proximally 15.3 ± 1.4 cm. The triceps inserted at a mean of 1.1 cm from the tip of the olecranon. Conclusions The distinct insertional heads of the triceps provides additional knowledge that can aid in diagnosing and treating partial triceps tears. In addition, a safe zone for capsulectomy and olecranon tip osteotomy is described that can be used to increase the safety of these procedures.

Background The medial patello-femoral ligament (MPFL) is a major patellar stabiliser whose reconstruction in adults involves graft fixation within a femoral tunnel. In skeletally immature patients, in contrast, the graft is fixed to the soft tissues to allow normal growth. The primary objective of this prospective study was to perform computed tomography (CT) and magnetic resonance imaging (MRI) assessments of medium-term correction of patellar tilt and of the axial patellar engagement index (AEI) after a paediatric variant of MPFL reconstruction in skeletally immature patients. Hypothesis MPFL reconstruction, performed alone or combined with other procedures in skeletally immature patients, decreases patellar tilt and improves the AEI. Material and methods Eighteen children and adolescents with a median age of 14.6 years (range, 8–17 years) who underwent MPFL reconstruction on 20 knees were included in this prospective observational study. A double-strand gracilis tendon graft passed through the medial collateral ligament was used. MPFL reconstruction was performed alone in 13 knees and was combined with lateral retinaculum release, tibial tuberosity translation, and/or trochleoplasty in 7 knees. Patellar tilt and AEI values determined on preoperative and post-operative imaging studies with the quadriceps relaxed and contracted were compared. A physical examination was also performed. Results From baseline to last follow-up after a mean of 43 months (range, 24–63 months), patellar tilt decreased from 20° preoperatively to 9° with the quadriceps relaxed and from 33° to 15.4° with the quadriceps contracted. The AEI increased from 0.78 at baseline to 0.93 at last follow-up. No dislocation or subluxation recurrences were recorded during follow-up. Discussion The patellar tilt and AEI improvements seen after paediatric MPFL reconstruction confirm the study hypothesis. This is the first prospective study of patellar position in the axial plane as assessed by CT and MRI after paediatric MPFL reconstruction. In everyday clinical practice, 3D assessments of patellar tilt and the AEI should be performed to evaluate correction of the abnormalities. Level of evidence II, non-randomised prospective observational study.

A 41-year-old active (exercising >600 min per week) male without a surgical history complained of nine years of intermittent bilateral anterior knee pain after physical activity. He was diagnosed with bilateral chondromalacia (grade IV chondrosis) with plica syndrome, for which he underwent bilateral patella cartilage debridement with medial plica excision (additional removal of lateral retinaculum in the right knee). The patient then performed 12 weeks of an aggressive postoperative rehabilitation program. Each rehabilitation session consisted of disinhibitory modalities (sensory level of transcutaneous electrical stimulation and cryotherapy: focal knee joint cooling and cold-water immersion) and voluntary exercises (aerobic, resistance, and flexibility). During rehabilitation, pain perception, knee joint skin temperature and circumference, and functional outcome measures (Kujala anterior knee pain scale, International Knee Documentation Committee Score, and lower-extremity functional scale) were also recorded. While the patient’s pathology and surgical intervention were not extreme, progressions in the rehabilitation components and functional outcome measures in this clinical case could be used as a future reference for postoperative interventions. Additionally, surgery-induced inflammation seemed to last for four weeks.

OBJECTIVES Chronic patellofemoral pain (PFP) is a common orthopedic condition for which little is understood of the alterations in pain processing such as hyperalgesia, hypoesthesia, and the relationship of altered knee mechanics to hyperalgesia. We assessed pain, pressure pain thresholds (PPT), detection to light touch, and the relationship of pain and PPTs to knee abduction angle during a stair step down task between females with and without PFP. MATERIALS AND METHODS Twenty females diagnosed with PFP and 20 age-matched pain-free females participated in this study. Individuals underwent an instrumented assessment of knee mechanics during a stair step down task, PPT and detection of light touch over the center of the patella and lateral retinaculum, and PPT outside painful area over the right elbow. RESULTS The PFP group had significantly lower PPT values at the patella (P=0.02), lateral retinaculum (P=0.001), and at the elbow (P=0.03). There was an elevated threshold to detect light touch over the center of their patella (P=0.04). A significant relationship between both pain (r=-0.49, P=0.03) and PPT values (r=0.65, P=0.004) to the frontal plane knee angle existed in the PFP group which was not present in the control group (r=-0.17, P=0.49) or in the elbow (r=-0.009, P=0.972). DISCUSSION These results suggest that PFP is characterized by an increase in both localized and centralized pain sensitivity that is related to movement mechanics. Thus, PFP has both biomechanical, nociceptive components as well as inferred aspects of altered central sensitization.