The symptomatic medial patellar plica is a definite but uncommon pathologic entity. Even after co... more The symptomatic medial patellar plica is a definite but uncommon pathologic entity. Even after complete excision of an inflamed, thickened plica, mild symptoms may persist despite considerable improvement. The plica syndrome may, in some cases, be part of a broader problem, possibly involving aberrant patellofemoral mechanics. Continued critical analysis of the disorder and the treatment results is necessary to clarify the syndrome further, but excision of a thickened, inflamed plica appears to be very helpful in most patients.
Historically, the patellofemoral articulation has been a topic of less interest among orthopaedis... more Historically, the patellofemoral articulation has been a topic of less interest among orthopaedists and has been subject to fewer studies when compared with other major joints in the body. Patellofemoral arthritis is a common and debilitating condition, and greater awareness of this has led to a new interest and recent increase in the number of clinical investigations pertaining to this condition. It is hoped that an overview of patellofemoral kinematics, forces, and contact patterns will help in understanding the progression of patellofemoral arthritis. Furthermore, this understanding will ultimately allow the surgeon to apply these basic principles to more effective nonsurgical and surgical treatment options. Treatment methods for patellofemoral arthritis include both conservative as well as surgical interventions. Specifically, these treatments range from stretching and water exercises to patellar realignment procedures and the recently developed procedure of custom patellofemora...
The Journal of the American Academy of Orthopaedic Surgeons, 2011
Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. It is... more Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. It is associated with recurrent patellar dislocation, but it is unclear whether the dysplasia is congenital, the result of lateral tracking and chronic instability, or caused by a combination of factors. Lateral radiographs elucidate the crossing sign and characteristic trochlear prominence. Recurrent patellofemoral instability is multifactorial, and each component must be considered in determining treatment. Managing other factors associated with recurrent instability may compensate for a deficient trochlea and provide stability. Medial patellofemoral ligament reconstruction is recommended for patellofemoral instability in the presence of trochlear dysplasia in patients without patella alta or increased tibial tubercle-trochlear groove distance. Trochleoplasty should be reserved for severe dysplasia in which patellofemoral stability cannot otherwise be obtained.
This is a retrospective study of one surgeon's experience performing anteromedialization of t... more This is a retrospective study of one surgeon's experience performing anteromedialization of the tibial tubercle for the treatment of isolated patellofemoral arthritis in active older patients. Patients were included if they were > 50 years at the time of the surgery and had a minimum follow-up of 2 years. Outerbridge classifications were documented by arthroscopy, and patellofemoral alignment was evaluated clinically and radiographically. Lysholm and Fern pain scores were obtained via mailed questionnaire or phone survey. A total of 22 anteromedialization procedures were performed on 17 patients who met the inclusion criteria; 82% of patients completed the followup survey. Mean age was 55 years. Mean follow-up was 77 months. Mean postoperative Lysholm score was 83. Based on Lysholm scores, there were 12 good to excellent, 6 fair, and 1 poor outcomes. Anteromedialization of the tibial tubercle is a definitive treatment option for isolated patellofemoral arthritis in active old...
Much as the anterior talofibular ligament can be advanced to stabilize the lateral ankle, the hea... more Much as the anterior talofibular ligament can be advanced to stabilize the lateral ankle, the healed, elongated medial patellofemoral ligament (MPFL) can be advanced to restore patellofemoral stability. We describe a simple technique whereby the MPFL remnant and femoral insertion can be easily identified and tested for integrity through a mini-open technique. In 13 consecutive cases after patellar dislocation, the MPFL was identified as a healed but elongated structure, with an intact, anatomically correct femoral insertion. Advancement of this healed, but elongated structure effectively restores stability in most patients. This helps in understanding why vastus medialis obliquus advancement has successfully restored patella stability in many patients after recurrent dislocation. MPFL advancement is an important alternative to full MPFL reconstruction in some patients.
Sixty-four patients with three different autografts were prospectively evaluated following anteri... more Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.
ABSTRACT The central quadriceps tendon (CQT) is a versatile graft for cruciate reconstruction, an... more ABSTRACT The central quadriceps tendon (CQT) is a versatile graft for cruciate reconstruction, and may be used with or without a bone plug from the proximal patella. The authors recommend using the graft with a bone plug fixed in the femoral socket until long-term results are available with alternative methods. CQT as a free graft, however, holds promise for the future of anterior cruciate ligament (ACL) reconstruction as an alternative that might reduce perioperative and eventual morbidity. There are no long-term results yet to justify the CQT free graft for routine ACL reconstruction until clinical trials at a few centers establish this as yielding comparable results to bone-tendon-bone or CQT/bone plug reconstruction at long-term follow up (C) Williams & Wilkins 1998. All Rights Reserved.
CQFT ACL reconstruction yields a stable, highly functional knee with little associated morbidity.... more CQFT ACL reconstruction yields a stable, highly functional knee with little associated morbidity. Patient satisfaction has been very high, and objective follow-up data collected thus far is very encouraging.
The Journal of Bone and Joint Surgery (American), 2009
Background: The experience of undergoing surgery is known to induce a short-term, fight-or-flight... more Background: The experience of undergoing surgery is known to induce a short-term, fight-or-flight physiological stress response. As an optimum immune response at the site of surgery would enhance tissue repair, we examined surgical stress-induced immune cell redistribution profiles as predictors, and potential mediators, of short and long-term postoperative recovery. We tested the a priori hypothesis that predefined adaptive immune cell redistribution profiles observed during surgery will predict enhanced postoperative recovery.
The Journal of Bone and Joint Surgery (American), 2005
In support of their research or preparation of this manuscript, one or more of the authors receiv... more In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Stryker Orthopaedics. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide ...
The Journal of Bone and Joint Surgery (American), 2012
The role of medial patellofemoral ligament reconstruction in reestablishing patellofemoral joint ... more The role of medial patellofemoral ligament reconstruction in reestablishing patellofemoral joint stability has recently been reported with increasing frequency. The purpose of this study was to review the reported complications of medial patellofemoral ligament reconstruction, highlight the common technical errors, and discuss the potential complications that can arise from this procedure. We review the literature on medial patellofemoral ligament reconstruction, including the reported causes of failure. In addition, we present three cases and discuss the multiple factors that are crucial for success, including patient selection, tunnel placement, graft isometry, and determination of the need for concurrent realignment surgery. The principles of surgical management require a thorough understanding of proper patient selection and of the interaction between the roles of the osseous and soft-tissue restraints on the patella. Creating a logical treatment algorithm based on pathoanatomy can elucidate the need for concurrent distal realignment procedures. Tunnel positioning is critical in recreating appropriate patellofemoral alignment. The reported complications include patellofemoral arthrosis, graft impingement, and graft failure. Many of the complications that can arise from medial patellofemoral ligament reconstruction are the result of technical error and can be avoided by understanding the potential complications associated with this procedure.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2011
In patients with chronic patellofemoral instability who have normal alignment and deficient proxi... more In patients with chronic patellofemoral instability who have normal alignment and deficient proximal medial restraints, medial patellofemoral ligament (MPFL) reconstruction is a good option to treat patellar instability. However, medial subluxation, medial patellofemoral articular overload, and recurrent lateral instability are possible when the graft is positioned non-anatomically. The clinical presentation of MPFL femoral tunnel malpositioning has not been highlighted in the literature. We have had 5 patients referred to us after a malpositioned femoral MPFL graft led to disabling symptoms and a need for revision surgery. This report highlights the effects of a malpositioned graft and describes strategies to identify the anatomic MPFL insertion during surgery.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2005
It has been demonstrated that the medial hamstring tendons regenerate in the majority of patients... more It has been demonstrated that the medial hamstring tendons regenerate in the majority of patients following their harvest for anterior cruciate ligament reconstruction. The anatomy and morphology of these regenerated tendons have been radiographically and surgically documented. The neotendons originate within the appropriate muscle belly but display an altered insertion anatomy. Their histological composition is largely tendinous but has regions that resemble scar tissue. Concordantly, an animal model indicates that the neotendon has decreased mechanical strength, which has implications for tendon re-harvest. The regenerated tendons do restore a muscle tendon complex that is able to generate force; however, strength testing indicates that the function of the hamstring muscles is altered by harvest and regeneration. The most significant strength deficits are present in deep knee flexion and internal rotation of the tibia, whereas the peak torque of knee flexion is minimally affected. Additional harvest of the gracilis tendon results in greater deficits. The current literature indicates that hamstring tendon regeneration does indeed occur, but with structural and functional alterations.
In this study of bioabsorbable screw fixation of free tendon grafts used in anterior cruciate lig... more In this study of bioabsorbable screw fixation of free tendon grafts used in anterior cruciate ligament reconstruction, we performed load-to-failure and cyclic loading of tendon fixation in porcine bone. Bone density measurements from dual photon absorptometry scans were obtained to correlate bone density with fixation failure. The average density of porcine bone (1.42 g/cm2) was similar to that of young human bone (1.30 g/cm2) and significantly higher than that of elderly human cadaveric bone specimens (0.30 g/cm2). Cyclic loading was performed on free tendon grafts fixed with a bioabsorbable screw alone and on grafts fixed with a bioabsorbable screw and an anchor (polylactic acid ball or cortical bone disk). Stiffness of fixation increased substantially with the addition of a cortical bone disk anchor or polylactic acid ball compared with the interference screw alone. Tensile fixation strength of central quadriceps free tendon and hamstring tendon grafts were significantly superior...
The symptomatic medial patellar plica is a definite but uncommon pathologic entity. Even after co... more The symptomatic medial patellar plica is a definite but uncommon pathologic entity. Even after complete excision of an inflamed, thickened plica, mild symptoms may persist despite considerable improvement. The plica syndrome may, in some cases, be part of a broader problem, possibly involving aberrant patellofemoral mechanics. Continued critical analysis of the disorder and the treatment results is necessary to clarify the syndrome further, but excision of a thickened, inflamed plica appears to be very helpful in most patients.
Historically, the patellofemoral articulation has been a topic of less interest among orthopaedis... more Historically, the patellofemoral articulation has been a topic of less interest among orthopaedists and has been subject to fewer studies when compared with other major joints in the body. Patellofemoral arthritis is a common and debilitating condition, and greater awareness of this has led to a new interest and recent increase in the number of clinical investigations pertaining to this condition. It is hoped that an overview of patellofemoral kinematics, forces, and contact patterns will help in understanding the progression of patellofemoral arthritis. Furthermore, this understanding will ultimately allow the surgeon to apply these basic principles to more effective nonsurgical and surgical treatment options. Treatment methods for patellofemoral arthritis include both conservative as well as surgical interventions. Specifically, these treatments range from stretching and water exercises to patellar realignment procedures and the recently developed procedure of custom patellofemora...
The Journal of the American Academy of Orthopaedic Surgeons, 2011
Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. It is... more Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. It is associated with recurrent patellar dislocation, but it is unclear whether the dysplasia is congenital, the result of lateral tracking and chronic instability, or caused by a combination of factors. Lateral radiographs elucidate the crossing sign and characteristic trochlear prominence. Recurrent patellofemoral instability is multifactorial, and each component must be considered in determining treatment. Managing other factors associated with recurrent instability may compensate for a deficient trochlea and provide stability. Medial patellofemoral ligament reconstruction is recommended for patellofemoral instability in the presence of trochlear dysplasia in patients without patella alta or increased tibial tubercle-trochlear groove distance. Trochleoplasty should be reserved for severe dysplasia in which patellofemoral stability cannot otherwise be obtained.
This is a retrospective study of one surgeon's experience performing anteromedialization of t... more This is a retrospective study of one surgeon's experience performing anteromedialization of the tibial tubercle for the treatment of isolated patellofemoral arthritis in active older patients. Patients were included if they were > 50 years at the time of the surgery and had a minimum follow-up of 2 years. Outerbridge classifications were documented by arthroscopy, and patellofemoral alignment was evaluated clinically and radiographically. Lysholm and Fern pain scores were obtained via mailed questionnaire or phone survey. A total of 22 anteromedialization procedures were performed on 17 patients who met the inclusion criteria; 82% of patients completed the followup survey. Mean age was 55 years. Mean follow-up was 77 months. Mean postoperative Lysholm score was 83. Based on Lysholm scores, there were 12 good to excellent, 6 fair, and 1 poor outcomes. Anteromedialization of the tibial tubercle is a definitive treatment option for isolated patellofemoral arthritis in active old...
Much as the anterior talofibular ligament can be advanced to stabilize the lateral ankle, the hea... more Much as the anterior talofibular ligament can be advanced to stabilize the lateral ankle, the healed, elongated medial patellofemoral ligament (MPFL) can be advanced to restore patellofemoral stability. We describe a simple technique whereby the MPFL remnant and femoral insertion can be easily identified and tested for integrity through a mini-open technique. In 13 consecutive cases after patellar dislocation, the MPFL was identified as a healed but elongated structure, with an intact, anatomically correct femoral insertion. Advancement of this healed, but elongated structure effectively restores stability in most patients. This helps in understanding why vastus medialis obliquus advancement has successfully restored patella stability in many patients after recurrent dislocation. MPFL advancement is an important alternative to full MPFL reconstruction in some patients.
Sixty-four patients with three different autografts were prospectively evaluated following anteri... more Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.
ABSTRACT The central quadriceps tendon (CQT) is a versatile graft for cruciate reconstruction, an... more ABSTRACT The central quadriceps tendon (CQT) is a versatile graft for cruciate reconstruction, and may be used with or without a bone plug from the proximal patella. The authors recommend using the graft with a bone plug fixed in the femoral socket until long-term results are available with alternative methods. CQT as a free graft, however, holds promise for the future of anterior cruciate ligament (ACL) reconstruction as an alternative that might reduce perioperative and eventual morbidity. There are no long-term results yet to justify the CQT free graft for routine ACL reconstruction until clinical trials at a few centers establish this as yielding comparable results to bone-tendon-bone or CQT/bone plug reconstruction at long-term follow up (C) Williams & Wilkins 1998. All Rights Reserved.
CQFT ACL reconstruction yields a stable, highly functional knee with little associated morbidity.... more CQFT ACL reconstruction yields a stable, highly functional knee with little associated morbidity. Patient satisfaction has been very high, and objective follow-up data collected thus far is very encouraging.
The Journal of Bone and Joint Surgery (American), 2009
Background: The experience of undergoing surgery is known to induce a short-term, fight-or-flight... more Background: The experience of undergoing surgery is known to induce a short-term, fight-or-flight physiological stress response. As an optimum immune response at the site of surgery would enhance tissue repair, we examined surgical stress-induced immune cell redistribution profiles as predictors, and potential mediators, of short and long-term postoperative recovery. We tested the a priori hypothesis that predefined adaptive immune cell redistribution profiles observed during surgery will predict enhanced postoperative recovery.
The Journal of Bone and Joint Surgery (American), 2005
In support of their research or preparation of this manuscript, one or more of the authors receiv... more In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Stryker Orthopaedics. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide ...
The Journal of Bone and Joint Surgery (American), 2012
The role of medial patellofemoral ligament reconstruction in reestablishing patellofemoral joint ... more The role of medial patellofemoral ligament reconstruction in reestablishing patellofemoral joint stability has recently been reported with increasing frequency. The purpose of this study was to review the reported complications of medial patellofemoral ligament reconstruction, highlight the common technical errors, and discuss the potential complications that can arise from this procedure. We review the literature on medial patellofemoral ligament reconstruction, including the reported causes of failure. In addition, we present three cases and discuss the multiple factors that are crucial for success, including patient selection, tunnel placement, graft isometry, and determination of the need for concurrent realignment surgery. The principles of surgical management require a thorough understanding of proper patient selection and of the interaction between the roles of the osseous and soft-tissue restraints on the patella. Creating a logical treatment algorithm based on pathoanatomy can elucidate the need for concurrent distal realignment procedures. Tunnel positioning is critical in recreating appropriate patellofemoral alignment. The reported complications include patellofemoral arthrosis, graft impingement, and graft failure. Many of the complications that can arise from medial patellofemoral ligament reconstruction are the result of technical error and can be avoided by understanding the potential complications associated with this procedure.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2011
In patients with chronic patellofemoral instability who have normal alignment and deficient proxi... more In patients with chronic patellofemoral instability who have normal alignment and deficient proximal medial restraints, medial patellofemoral ligament (MPFL) reconstruction is a good option to treat patellar instability. However, medial subluxation, medial patellofemoral articular overload, and recurrent lateral instability are possible when the graft is positioned non-anatomically. The clinical presentation of MPFL femoral tunnel malpositioning has not been highlighted in the literature. We have had 5 patients referred to us after a malpositioned femoral MPFL graft led to disabling symptoms and a need for revision surgery. This report highlights the effects of a malpositioned graft and describes strategies to identify the anatomic MPFL insertion during surgery.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2005
It has been demonstrated that the medial hamstring tendons regenerate in the majority of patients... more It has been demonstrated that the medial hamstring tendons regenerate in the majority of patients following their harvest for anterior cruciate ligament reconstruction. The anatomy and morphology of these regenerated tendons have been radiographically and surgically documented. The neotendons originate within the appropriate muscle belly but display an altered insertion anatomy. Their histological composition is largely tendinous but has regions that resemble scar tissue. Concordantly, an animal model indicates that the neotendon has decreased mechanical strength, which has implications for tendon re-harvest. The regenerated tendons do restore a muscle tendon complex that is able to generate force; however, strength testing indicates that the function of the hamstring muscles is altered by harvest and regeneration. The most significant strength deficits are present in deep knee flexion and internal rotation of the tibia, whereas the peak torque of knee flexion is minimally affected. Additional harvest of the gracilis tendon results in greater deficits. The current literature indicates that hamstring tendon regeneration does indeed occur, but with structural and functional alterations.
In this study of bioabsorbable screw fixation of free tendon grafts used in anterior cruciate lig... more In this study of bioabsorbable screw fixation of free tendon grafts used in anterior cruciate ligament reconstruction, we performed load-to-failure and cyclic loading of tendon fixation in porcine bone. Bone density measurements from dual photon absorptometry scans were obtained to correlate bone density with fixation failure. The average density of porcine bone (1.42 g/cm2) was similar to that of young human bone (1.30 g/cm2) and significantly higher than that of elderly human cadaveric bone specimens (0.30 g/cm2). Cyclic loading was performed on free tendon grafts fixed with a bioabsorbable screw alone and on grafts fixed with a bioabsorbable screw and an anchor (polylactic acid ball or cortical bone disk). Stiffness of fixation increased substantially with the addition of a cortical bone disk anchor or polylactic acid ball compared with the interference screw alone. Tensile fixation strength of central quadriceps free tendon and hamstring tendon grafts were significantly superior...
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