Thomas V Smallman

SUNY: Upstate Medical University, Orthopedic Surgery, Faculty Member

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I am an orthopaedic surgeon working at Auburn Community Hospital, and affiliated with the Department of Orthopaedic Surgery, Upstate Medical University. Our research group has included Kris Shekitka (anatomic pathologist), Amos Race and Ken Mann (biomedical engineers), Oliver Portner and myself (orthopaedic surgeons). My current research interest has to do with the pathophysiology and treatment of anterior knee pain (AKP), or the patellofemoral pain syndrome. Our group has completed research that describes new information on the anatomy and physiology of the knee, linking the structure (gross and microscopic anatomy) and function (kinematic behavior) to AKP, an unsolved problem that spans many clinical disciplines (pediatrics, rheumatology, physiatry, sports medicine, and orthopaedic surgery). Our research has defined a common factor that underlies knee pain in general, and links AKP anatomically to the contents of the anterior compartment of the knee, the infrapatellar plica (ligamentum mucosum) and the fat pad. From a serendipitous observation made during the knee arthroscopy of a very fit male with unresolved AKP in 1990, we have developed an alternative surgical approach to AKP which is safe, and reliable.
Phone: (315) 415-0612
Address: 3 Chestnut Circle
Skaneateles, NY, 13152-1301

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Università degli Studi "La Sapienza" di Roma

Marco Crostelli

Osvaldo Mazza

Children's Hospital 'Bambino Gesù' Rome

Ciro Villani

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Papers by Thomas V Smallman

Arthroscopic surgery of the knee: Its role in the support of U.S. troops during Operation Desert Shield on USNS Mercy

Arthroscopy, Sep 1, 1992

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Intra-operative visualization of deformation of the infrapatellar plica and fat pad – the link to anterior knee pain

F1000Research, 2015

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Resection of the infrapatellar plica for adolescent anterior knee pain: successful treatment with long-term follow-Up

F1000Research, 2015

This study demonstrates that arthroscopic release of the infrapatellar plica (IPP) can relieve th... more This study demonstrates that arthroscopic release of the infrapatellar plica (IPP) can relieve the problem of adolescent anterior knee pain (AAKP) in pediatric patients not responding to conservative management. BACKGROUND DATA Adolescent Anterior Knee Pain (AAKP) is an unsolved problem affecting millions of children worldwide. DEFINITION: a clinical syndrome in children characterized by mechanical pain perceived primarily at the front of the knee often associated with crepitation. CHARACTERISTICS: • Onset: insidious, or abrupt following trauma, or overuse • Course: in most-benign, and self-limited; in 25-45% pain becomes chronic, with long term sequelae; both physical and mental • Significant pain is ongoing 1,2,3 • Higher levels of mental distress, lower levels of self-perceived health 4 • Child adopts the coping skills of chronic pain patients. 5,6

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The Gross Anatomy and Histology of the Infrapatellar Plica, Central Body and Fat Pad Suggests That They Function as an Enthesis Organ

This study documents the gross and histologic structure of the infrapatellar plica, and fat pad, ... more This study documents the gross and histologic structure of the infrapatellar plica, and fat pad, and adds to an earlier report to the COA. The important new findings are that the femoral attachment of the plica is an enthesis, and that the plica itself is. This study seeks to demonstrate that the structure of the fat pad (FP) and infrapatellar plica (IPP) is that of an enthesis organ. Twelve fresh frozen cadaver knees, each with an IPP, were dissected and the gross anatomic features recorded. The IPP and FP were harvested for study. Representative histologic sections were prepared on tissue fixed in 10% neutral buffered formalin, embedded in paraffin, cut at 4 microns on a rotatory microtome. Staining techniques included hematoxylin and eosin, Masson9s trichrome, elastic stain and S100. Appropriate decalcification of sections of the femoral insertion of the IPP was performed. All sections were examined by light microscopy at low, medium and high power. IPP types included 8 separate,...

Intra-Operative fluoroscopic findings demonstrate deformation of the infrapatellar plica and fat pad with knee motion; release of the infrapatellar plica eliminates the distortion establishing an anatomic link to anterior knee pain

F1000Research, 2015

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The infrapatellar fat pad and plica – gross anatomy, and histology suggesting that the infrapatellar plica functions as an intra-articular ligament: a preliminary report

F1000Research, 2015

This study seeks to demonstrate the gross anatomy and histology of the infrapatellar fat pad (FP)... more This study seeks to demonstrate the gross anatomy and histology of the infrapatellar fat pad (FP) and infrapatellar plica (IPP) with a view to emphasizing that they are part of a structural and biomechanical continuum, one function of which is to transmit force. The histology of these structures has not been reported in the orthopaedic literature.

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The Mechanical Link Between the Infrapatellar Plica and the Fat Pad – Role in the Etiology of Anterior Knee Pain

Journal of Bone Joint Surgery British Volume, Sep 1, 2012

Purpose Anterior knee pain has been relieved by resection of the infrapatellar plica (IPP). The q... more Purpose Anterior knee pain has been relieved by resection of the infrapatellar plica (IPP). The question is: How? The hypothesis is: the IPP acts as an intra-articular ligament, a mechanical link between the forces of knee motion, the fat pad (FP) and the distal femur, holding the FP captive through the arc of motion. Release of the IPP severs this link, allowing the highly innervated FP to move freely. This may allow any underlying pathologic process to heal. Method Anatomic dissection: In 12 knees, the extensor apparatus was released from the femur and retracted distally allowing relationships to be examined. Cadaver studies: Lateral fluoroscopy was used as well as direct arthroscopic visualization to control implantation of tantalum beads or radiographic contrast material in the FP and IPP. The knee was taken through the arc of motion repeatedly. The femoral attachment of the IPP was then released and knee motion repeated. Traction on the extensor apparatus simulated active motion. In-Vivo Study: The IRB approved study of 12 volunteers undergoing planned knee arthroscopy under local anesthesia. Contrast was placed in the FP and IPP under lateral fluoroscopic control. Passive, then active motion then a quads-set manoeuvre was performed. The IPP was resected and knee motion again recorded. Results Knees without IPP (4) demonstrated FPs that were lobular, with lateral bodies, and a central process. The fibrous synovial layer of the capsule bypassed the FP inserting on the superior aspect of the menisci. Knees with an IPP (8) showed a FP that was covered by fibrous synovium. The fibrous elements of the capsule coalesced on either side of the patellar in folds that merged with the alar folds. These fibrous elements ramified over and through the FP and were continuous with the upper portion of the IPP medially and laterally. Inferiorly the lower portion of the IPP merged with fibrous synovium that attached to the superior aspect of the menisci and the inter-meniscal ligament. The cadaver studies demonstrated that the IPP elongated with FP distortion as the knee approached full extension and flexion, and that the IPP was lax through mid arc. Release of the IPP at the femur eliminated almost all of the distortion through the full arc. The In-Vivo study replicated the cadaver observations for passive and active motion. The quads set manoeuvre caused further distortion of the FP with the patella moving one cm proximally. Release of the IPP eliminated FP distortion. Conclusion The IPP seems to act as a true ligamentum mucosum. By virtue of its central femoral attachment if captures the FP against the end of the femur, loosely in mid arc, but with distortion of the FP and stretch of the IPP approaching full flexion and extension. This has been demonstrated in both cadavers and in in-vivo for the first time. Any pathologic process affecting the highly innervated FP will likely be improved by removal of the capture effect of the IPP.

EFORT12-4308 The Link between the Structure and Function of the Infrapatellar Plica and Anterior Knee Pain

INTRODUCTION: Wachtler3 in 1979 described the histology of the IPP and discussed its function. Be... more INTRODUCTION: Wachtler3 in 1979 described the histology of the IPP and discussed its function. Beyond the histology, he injected the fat pad (FP) and noted from his observations that “…from a mechanical and teleological point of view, the IPP may have little relevance…” By contrast, anterior knee pain has been relieved by resection of the infrapatellar plica (IPP)1,2. The question is: How? The hypothesis is: that the IPP acts as an intra-articular ligament, a mechanical link between the motors of knee motion, the fat pad (FP) and the distal femur, holding the FP captive through the arc of motion. Release of the IPP severs this link, allowing the highly innervated FP to move freely. This study reports on replication of Wachtler's study with the addition of in-vivo verification. The remarkable videos are at variance with Wachtler's opinion and suggest a distinct mechanical role for this structure. OBJECTIVES: In cadaver knees to inject the FP and IPP with radiographic contrast...

EFORT12-5557 Resection of the Infrapatellar Plica for Adolescent Anterior Knee Pain – Successful Treatment with Long-Term Follow-Up

INTRODUCTION: Adolescent anterior knee pain (AAKP) is a common, enigmatic condition that has no k... more INTRODUCTION: Adolescent anterior knee pain (AAKP) is a common, enigmatic condition that has no known etiology, no confirmatory physical findings, and is generally managed conservatively. When conservative management fails the long-term consequences can be devastating1,2. This study is a report on paediatric patients not responding to conservative management for AAKP, who were treated by arthroscopic release of the infrapatellar plica (IPP). OBJECTIVES: To confirm a treatment algorithm for patients with AAKP. To report the surgical results of this algorithm. METHODS: This is a retrospective study of 35 patients who presented to a general orthopaedic surgeon with 49 symptomatic knees over an 18 year period in three geographic locations. After failure of non-operative management, patients were treated by arthroscopic resection of the infrapatellar plica (release at the femoral attachment). Outcome measurements included standardized subjective knee scales: the Lysholm Scale, and the Ac...

ID 752: The Infrapatellar Fat Pad and Plica: Gross Anatomy, and Histology Suggesting that the Infrapatellar Plica Functions as an Intra-articular Ligament – a Preliminary Report

Purpose: This study seeks to demonstrate the gross anatomy of the infrapatellar fat pad (FP) and ... more Purpose: This study seeks to demonstrate the gross anatomy of the infrapatellar fat pad (FP) and infrapatellar plica (IPP). The histology of the IPP will be reported. Method: Twelve cadaver knees were dissected, maintaining the extensor apparatus and attachments to the knee intact. Reflection of the extensor apparatus allowed relationships to be examined from a unique perspective. Histological study of the IPP was performed: of the insertion to the central FP , central IPP, and femoral insertion of the IPP, using hematoxylin and eosin, and trichrome stains. Results: Gross inspection of knees without IPP (4) demonstrated FPs that were lobular, with lateral bodies, and a central process. The fibrous synovial layer of the capsule bypassed the FP, inserting on either side to the superior aspect of the menisci. Knees with an IPP (8) showed a FP that was covered by fibrous synovium. The fibrous elements of the capsule coalesced on either side of the patella in folds that merged with the a...

ID 675: Resection of the Infrapatellar Plica for Adolescent Anterior Knee Pain – Successful Treatment with Long-Term Follow-Up

Purpose: This study seeks to demonstrate that in paediatric patients not responding to conservati... more Purpose: This study seeks to demonstrate that in paediatric patients not responding to conservative management for adolescent anterior knee pain (AAKP), arthroscopic release of the infrapatellar plica (IPP) successfully relieves the problem. Method: This is a retrospective study of 23 patients who presented to a general orthopaedic surgeon with 31 symptomatic knees over an 18 year period in three geographic locations. After failure of non-operative management, patients were treated by arthroscopic resection of the infrapatellar plica (release at the femoral attachment). Outcome measurements included the Lysholm Scale and the Activities of Daily Living Scale of the Knee Outcome Survey (KOS). The follow-up period was from 11 months to 15 years, with a mean of 47 months. Results: The KOS scores reflected a good/excellent outcome in 87% (27/31), excellent (19) or good (eight) at follow-up. Lysholm scores increased significantly (p < 0.0001, paired t-test) from 39.8 (SD 12.9, range 16...

ID705: The Mechanical Link between the Infrapatellar Plica and the Fat Pad -- Role in the Etiology of Anterior Knee Pain

Purpose: Anterior knee pain has been relieved by resection of the infrapatellar plica (IPP). The ... more Purpose: Anterior knee pain has been relieved by resection of the infrapatellar plica (IPP). The question is: How? The hypothesis is: the IPP acts as an intra-articular ligament, a mechanical link between the forces of knee motion, the fat pad (FP) and the distal femur, holding the FP captive through the arc of motion. Release of the IPP severs this link, allowing the highly innervated FP to move freely. This may allow any underlying pathologic process to heal. Method: Anatomic dissection: In 12 knees, the extensor apparatus was released from the femur and retracted distally allowing relationships to be examined. Cadaver studies: Lateral fluoroscopy was used as well as direct arthroscopic visualization to control implantation of tantalum beads or radiographic contrast material in the FP and IPP. The knee was taken through the arc of motion repeatedly. The femoral attachment of the IPP was then released and knee motion repeated. Traction on the extensor apparatus simulated active mot...

ISAKOS ABSTRACT 7421 Intra-Operative Fluoroscopic Findings Demonstrate Deformation Of The Infrapatellar Plica And Fat Pad With Knee Motion; Release Of The Infrapatellar Plica Eliminates The Distortion Establishing An Anatomic Link To Anterior Knee Pain

Summary: This study reports the kinematics of the infrapatellar plica and fat pad, observed throu... more Summary: This study reports the kinematics of the infrapatellar plica and fat pad, observed through fluoroscopy, with demonstration of deformation of these structures as the knee approaches full extension, and elimination of the distortion with release of the plica. This suggests an anatomic link to anterior knee pain. INTRODUCTION: Wachtler (3) in 1979 described the teleology, anatomy, and histology of the plica synovialis infrapatellaris (IPP) and discussed its function. Beyond describing the histology, he injected the fat pad (FP) and noted, “…from a mechanical and teleological point of view, the IPP may have little relevance…”. However, in clinical practice, anterior knee pain has been relieved by resection of the IPP. (1,2) The question is: How? Our working hypothesis, based on arthroscopic observation of the IPP, supported by histological data (3) is that the IPP acts as a non-isometric intra-articular ligament originating at its bony femoral attachment, spanning the gap of th...

AANA 109 Intra-operative Visualization of Deformation of the Infrapatellar Plica (IPP), and Fat Pad -- The Link to Anterior Knee Pain

PURPOSE: Wachtler in 1979 described the plica synovialis infrapatellaris (IPP) and discussed its ... more PURPOSE: Wachtler in 1979 described the plica synovialis infrapatellaris (IPP) and discussed its function. Beyond describing the histology, he injected the fat pad (FP) and noted, “the IPP may have little relevance”. However Boyd and Demirag have demonstrated reiief of anterior knee pain by resection of the IPP. The question is: How? Our hypothesis, based on arthroscopic observation, supported by histological data is that the IPP acts as a non-isometric ligament. This study replicates Wachtler's original study using cadavers with in-vivo arthroscopic verification of the demonstrated kinematics. The objectives are: to inject the FP and IPP of cadaver knees with radiographic contrast, and observe motion using lateral fluoroscopy; and to repeat the experiment in awake volunteers undergoing arthroscopy. METHODS: In 2 embalmed cadaver knees; arthroscopy was performed to verify normal anatomy and the presence of an IPP. Radiographic contrast material was placed in the FP and IPP. The ...

ISAKOS E-POSTER 7421: Intra-Operative Fluoroscopic Findings Demonstrate Deformation Of The Infrapatellar Plica And Fat Pad With Knee Motion; Release Of The Infrapatellar Plica Eliminates The Distortion Establishing An Anatomic Link To Anterior Knee Pain

The Infrapatellar Plica And Fat Pad: Fluoroscopy, Gross Anatomy, And Histology Suggest That The I... more The Infrapatellar Plica And Fat Pad: Fluoroscopy, Gross Anatomy, And Histology Suggest That The Infrapatellar Plica Functions As A Non-Isometric Intra-Articular Ligament – A Preliminary Report Thomas Victor Smallman BSC, MSC, MD, FRCS(C), Skaneateles, New York, USA, Presenter Amos Race PhD, Syracuse, NY, USAKris Shekitka MD, Baltimore, MD, USA Kenneth A Mann PhD, Syracuse, NY, USA John Riccio MD, Auburn, NY, USA Upstate Medical University, Syracuse, NY, USA SUMMARY: By virtue of anatomical location, the infrapatellar plica of the knee is a non-isometric ligament attaching the fat pad to the femur as the fat pad rotates around the apex of the notch; knee motion thus imparts stretch and relaxation to the plica and attached, highly innervated central body of the fat pad; the link to anterior knee pain is that release of the plica offers relief in most. INTRODUCTION: In nature structure and function are linked. Wachtler 1 in Plica synovialis infrapatellaris in man described the histolog...

AANA e090 Intra-operative Visualization of Deformation of the Infrapatellar Plica and Fat Pad -- The Link to Anterior Knee Pain

Purpose Wachtler in 1979 described the plica synovialis infrapatellaris (IPP) and discussed its f... more Purpose Wachtler in 1979 described the plica synovialis infrapatellaris (IPP) and discussed its function. Beyond describing the histology, he injected the fat pad (FP) and noted, “the IPP may have little relevance”. However Boyd and Demirag have demonstrated reiief of anterior knee pain by resection of the IPP. The question is: How? Our hypothesis, based on arthroscopic observation, supported by histological data is that the IPP acts as a non-isometric ligament. This study replicates Wachtler's original study using cadavers with in-vivo arthroscopic verification of the demonstrated kinematics. The objectives are: to inject the FP and IPP of cadaver knees with radiographic contrast, and observe motion using lateral fluoroscopy; and to repeat the experiment in awake volunteers undergoing arthroscopy. Methods In 2 embalmed cadaver knees; arthroscopy was performed to verify normal anatomy and the presence of an IPP. Radiographic contrast material was placed in the FP and IPP. The kn...

Arthroscopic Untethering of the Fat Pad of the Knee: Release or Resection of the Infrapatellar Plica (Ligamentum Mucosum) and Related Structures for Anterior Knee Pain

Arthroscopy Techniques, 2018

Anterior knee pain (AKP), a multifactorial symptom complex, can be successfully treated surgicall... more Anterior knee pain (AKP), a multifactorial symptom complex, can be successfully treated surgically. A specific diagnosis often cannot be made, but the pain is linked to an unrecognized common factor in most patients: the mechanical behavior of the non-isometric contents of the anterior compartment of the kneedthe fat pad (FP) and infrapatellar plica (IPP). The objective of this presentation is to describe an effective arthroscopic technique that treats AKP by addressing this common factor. The operation consists of release or resection of the IPP, or ligamentum mucosum, which tethers the FP. These highly innervated tissues act together as a hydraulic shock absorber, filling the anterior compartment. They stretch and deform at the extremes of knee motion because of constraint centrally by the non-isometric IPP. These dynamic changes in shape are eliminated when the plica is released or resected. Pain perception is from perturbed nociceptive nerves: pain relief results from de-tensioning these contained nerves by untethering the fat pad. Ascribing pain causation is problematic because morphologic change, such as inflammation, fibrosis, or contracture of these structures, is only present in a minority of cases. Nonetheless, AKP is both physically linked to these central, pain-sensitive structures and relieved by this operation.

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The Mechanical Link Between the Infrapatellar Plica and the Fat Pad -- Role in the Etiology of Anterior Knee Pain

Intra-operative Visualization of Deformation of the Infrapatellar Plica (IPP), and Fat Pad -- The Link to Anterior Knee Pain