Patella subluxation assessed on dynamic MRI has previously been shown to be associated with anterior knee pain. In this MRI study of 60 patients we investigated the relationship between subluxation and multiple bony, cartilaginous and soft-tissue factors that might predispose to subluxation using discriminant function analysis. Patella engagement (% of patella cartilage overlapping with trochlea cartilage) had the strongest relationship with subluxation. Patellae with > 30% engagement tended not to sublux; those with < 30% tended to sublux. Other factors that were associated with subluxation included the tibial tubercle-trochlea notch distance, vastus medialis obliquus distance from patella, patella alta, and the bony and cartilaginous sulcus angles in the superior part of the trochlea. No relationship was found between subluxation and sulcus angles for cartilage and bone in the middle and lower part of the trochlea, cartilage thicknesses and Wiberg classification of the patella. This study indicates that patella engagement is a key factor associated with patellar subluxation. This suggests that in patients with anterior knee pain with subluxation, resistant to conservative management, surgery directed towards improving patella engagement should be considered. A clinical trial is necessary to test this hypothesis

Dislocation is a common and well-studied complication after total hip replacement. However, subluxation, which we define as a clinically recognised episode of incomplete movement of the femoral head outside the acetabulum with spontaneous reduction, has not been studied previously. Out of a total of 2521 hip replacements performed over 12 years by one surgeon, 30 patients experienced subluxations which occurred in 31 arthroplasties. Data were collected prospectively with a minimum follow-up of two years. Subluxation occurred significantly more frequently after revision than after primary hip replacement, and resolved in 19 of 31 cases (61.3%). In six of the 31 hips (19.4%) the patient subsequently dislocated the affected hip, and in six hips (19.4%) intermittent subluxation continued. Four patients had a revision operation for instability, three for recurrent dislocation and one for recurrent subluxation. Clinical and radiological comparisons with a matched group of stable total hips showed no correlation with demographic or radiological parameters. Patients with subluxing hips reported significantly more concern that their hip would dislocate, more often changed their behaviour to prevent instability and had lower postoperative Harris hip scores than patients with stable replacements

Abstract. Background. Little scientific evidence is available regarding the effect of knee joint line obliquity (JLO). Methods. 10 fresh-frozen human cadaveric knees were axially loaded to 1500 N in a materials testing machine with the joint line tilted 0, 4, 8, and 12 degrees varus and valgus, at 0, and 20 degrees of knee flexion. The mechanical compression axis was aligned to the centre of the tibial plateau. Contact pressures / areas were recorded by sensors inserted between the tibia and femur below the menisci. Changes in relative femoral and tibial position in the coronal plane were obtained by an optical tracking system. Results. medial and lateral JLO caused significant tibiofemoral subluxation and pressure distribution changes. Medial (varus) JLO caused the femur to sublux medially down the coronal slope of the tibial plateau, and vice versa for lateral (valgus) downslopes (P=0.01). Areas of peak pressure moved 12 mm and 8 mm across the medial and lateral condyles, onto the ‘downhill’ meniscus and the ‘uphill’ tibial spine. Changes in JLO had only small effects on maximum contact pressures. Conclusion. A change of JLO during load bearing caused significant mediolateral tibiofemoral subluxation. The femur slid down the slope of the tibial plateau to abut the tibial eminence and also to rest on the downhill meniscus. Clinical Relevance. These results provide important information for understanding the consequences of creating coronal JLO and for clinical practice in terms of osteotomy planning regarding the effect on JLO

Introduction: Patellofemoral joint subluxation is associated with pain and dysfunction. The causes of patel-lofemoral subluxation are poorly understood and multi-factorial, arising from abnormalities of both bone and soft tissues. This study aims to identify which anatomical variables assessed on Magnetic Resonance (MR) images are most relevant to patellofemoral subluxation. Method: A retrospective analysis of MR studies of 60 patients with suspected patellofemoral subluxation was performed. All patients were graded for the severity/ magnitude of radiological subluxation using a dynamic MR scan (Grade 0 [nil] to Grade 3 [subluxed]. The patient scans were assessed using a range of anatomical variables, these included:. Patella alta,. Patella type (Wiberg classification),. Trochlea sulcus angles for bone and cartilage,. The shortest horizontal distance between the most distal part of the vastus medialis obliquis (VMO) muscle to the supra-medial aspect of the patella,. Trochlea and patella cartilage thickness (maximum depth),. The horizontal distance between the tibial tubercle and the midpoint of the femoral trochlea (TTD),. Patella Engagement – represented as the percentage of the patella height that is captured in the trochlea groove when the knee is in full extension,. A Discriminant Analysis test for multi-variant analysis was applied to establish the relationship between each bony/soft tissue anatomical variable and the severity/magnitude of patellofemoral subluxation. Results: The distance of the VMO from the patella (p < 0.001), TTD (p < 0.001) and Patella Engagement (p < 0.001) showed highly significant relationships with patellofemoral subluxation. Conclusions: The following three anatomical variables are associated with patellofemoral subluxation: the distance of the VMO muscle from the patella, TTD and Patella Engagement. This is the first study to establish that patella engagement is related to PFJ subluxation showing that the lower the percentage engagement of the patella in the trochlea, the greater the severity/magnitude of patellofemoral subluxation. The finding provides greater insight into the aetiology and understanding of the mechanism of symptomatic PFJ subluxation

Acute angulation at the thoracolumbar junction with segmental subluxation of the spine occurring at the level above an anteriorly hypoplastic vertebra in otherwise normal children is a rare condition described as infantile developmental thoracolumbar kyphosis. Three patient series with total of 18 children have been reported in the literature. We report five children who presented with thoracolumbar kyphosis and discuss the treatment algorithm. We reviewed the medical records and spinal imaging at initial clinical presentation and at minimum two-year follow-up. The mean age at presentation was eight months (two to 12). All five children had L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously in three children kept under monitoring. In contrast, the deformity was progressive in two patients who were treated with bracing. The kyphosis and segmental subluxation corrected at latest follow-up (mean age 52 months; 48 to 60) in all patients with near complete reconstitution of the anomalous vertebra. The deformity and radiological imaging on a young child can cause anxiety to both parents and treating physicians. Diagnostic workup and treatment algorithm in the management of infantile developmental thoracolumbar kyphosis is proposed. Observation is indicated for non-progressive kyphosis and bracing if there is evidence of kyphosis and segmental subluxation deterioration beyond walking age. Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment. . Cite this article: Bone Joint J 2015;97-B:982–7

Metal-on-Metal devices generate significantly lower volumetric wear than conventional total hip replacements. However, clinically some patients may suffer some form of laxity in their joints leading to subluxation of the joint, which in turn may cause edge loading of an implant thereby increasing the chances of failure due to higher than expected wear. In this study, the effect of subluxation on MoM implant wear was investigated on a hip joint simulator. Materials & Methods. Two groups of 44 mm MoM devices were tested, n=3 in each group. The devices were subjected to 1 and 2 mm of subluxation. The flexion/extension was 30° and 15° respectively, internal/external rotation was ±10°, and cup inclination was 35°. The force was Paul type stance phase loading with a maximum load of 3 kN, with ISO swing phase load of 0.3 kN, run at 1 Hz. The test was carried out on a ProSim deep flexion & subluxation hip wear simulator (SimSol, UK). Rather than separating the head and the cup (microseparation), or reducing the swing phase load, this simulator is equipped with a novel mechanism to achieve translation of the head, while subjecting the devices to subluxation. During the swing phase, a controlled lateral force necessary for the translation of the head is applied by a cam mechanism, head retraction will then take place on heel strike. The lubricant used was new born calf serum with 0.2 wt. % sodium azide concentration diluted with de-ionised water to achieve average protein concentration of 20 g/l. Lubricant was changed every 250k cycles. Gravimetric wear measurements have been taken at 0.25 & 0.5 Mc stages. Results. Tests conducted with 1mm (Group 1) and 2mm (Group 2) subluxation significantly increased volumetric wear compared to standard hip simulator tests [1]. At 0.5 million cycles, group 1 and 2 produced an average volume loss of 4.38±0.98 mm. 3. (95% CL) and 7.07±1.64 mm. 3. (95% CL) respectively. Discussion/conclusion. Well positioned and well-fixed hip implants perform well in vitro and in vivo; however optimal performance a device can be affected by a number of factors from design, technical factors, patient factors, surgical technique to position of the device in vivo. The study presents test results of a hip joint simulator with a subluxation mechanism to simulate clinically relevant subluxation during the swing phase of a gait cycle under the ISO swing phase load of 0.3kN, with differing levels of luxation. Increasing the level of subluxation in turn increased volumetric wear due to greater head contact at the superior rim of the cup. Further tests will be conducted with high cup inclination angles (>45°) and subluxation to determine the effect upon wear. Tests which can simulate the (ideal and adverse) conditions clinically can help to improve the design and understanding of implant behaviour in vivo

Subluxation of the hip is common in patients with intermediate spinal muscular atrophy. This retrospective study aimed to investigate the influence of surgery on pain and function, as well as the natural history of subluxed hips which were treated conservatively. Thirty patients were assessed clinically and radiologically. Of the nine who underwent surgery only one reported satisfaction and four had recurrent subluxation. Of the 21 patients who had no surgery, 18 had subluxation at the latest follow-up, but only one reported pain in the hip. We conclude that surgery for subluxation of the hip in these patients is not justified

INTRODUCTION. Analysis of retrieved ceramic components have shown areas of localized ‘stripe wear’, which have been attributed to joint laxity and/or impingement resulting in subluxation of the head, causing wear on the edge of the cup. Studies have been conducted into the effects of mild subluxation, however few in vitro tests have looked at severe subluxation. The aim of this study was to develop a more clinically relevant subluxation protocol. MATERIALS & METHODS. Seven (Subluxation n=4; standard test n=3) of 36mm Biolox Forte (R3, Smith & Nephew) ceramic devices were tested for 0.5m cycles (mc). Two of the subluxed joints were further tested to 1 Mc. The devices were subjected to subluxation under standard testing conditions. The flex/ext was 30° and 15° respectively, with internal/external rotation of ±10°. The force was Paul type stance phase loading with a maximum load of 3 kN, and a standard ISO swing phase load of 0.3 kN at 1 Hz. The test was conducted on a ProSim hip joint wear simulator (SimSol, UK). The simulator is equipped with a novel mechanism to achieve translation of the head, to achieve subluxation. During the ISO swing phase load of 0.3kN, a controlled lateral force required for the translation of the head is applied by a cam mechanism, head retraction then occurs during heel strike. The lubricant used was new born calf serum diluted with de-ionised water to achieve average protein concentration of 20 g/l, with 0.2 wt % concentration NaN3, and changed every 250k cycles. Measurements have been taken at 0.5 & 1 mc stages. RESULTS. Linear wear measurements conducted on the subluxed joints resulted in stripe wear similar to that reported in vivo. Average length, width and depth dimensions were 25.34±1.96 mm, 8±1.60 mm and 16.95±3.87 μm (± 95% CL) respectively. Linear wear at 0.5 Mc for standard joints, were undistinguishable from the original profile. Gravimetrically, weight loss was undetectable for joints tested under standard conditions. The volume loss of the joints under subluxation was 1.9± 0.7 mm3 at 0.5 mc. Two joints tested to 1mc generated an average volume loss of 3.1±2.3 mm3. The stripe wear length, width and depth at 1 Mc were 25.30±3.33mm, 8±3.92mm and 35±17.07 μm respectiveley. DISCUSSION. The current study presents test results of a hip joint simulator with a novel subluxation mechanism to simulate severe and clinically relevant hip joint. Past techniques have had to reduce the swing phase load to achieve stripe wear patches of varying size and depth. The subluxed joints produced significantly higher volumetric wear than the standard joints. Dimensional measurements in terms of length, width and depth of wear patches of subluxed joints generated similar results to that which have been observed following retrieval analysis. Tests that can simulate different types of activity in hip joint simulators will help to improve the design and understanding of implant behaviour in vivo

We report five children who presented at the mean age of 1.5 years (1.1 to 1.9) with a progressive thoracolumbar kyphosis associated with segmental instability and subluxation of the spine at the level above an anteriorly-wedged hypoplastic vertebra at L1 or L2. The spinal deformity appeared to be developmental and not congenital in origin. The anterior wedging of the vertebra may have been secondary to localised segmental instability and subsequent kyphotic deformity. We suggest the term ‘infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine’ to differentiate this type of deformity from congenital displacement of the spine in which the congenital vertebral anomaly does not resolve. Infantile developmental kyphosis with segmental subluxation of the spine, if progressive, may carry the risk of neurological compromise. In all of our patients the kyphotic deformity progressed over a period of three months and all were treated by localised posterior spinal fusion. At a mean follow-up of 6.6 years (5.0 to 9.0), gradual correction of the kyphosis was seen on serial radiographs as well as reconstitution of the hypoplastic wedged vertebra to normality. Exploration of the arthrodesis was necessary at nine months in one patient who developed a pseudarthrosis

1. This paper presents the neurological findings in forty-one patients with rheumatoid arthritis complicated by atlanto-axial subluxation. 2. A method of radiological measurement of the subluxation is described. The extent of neurological involvement was found not to correspond with the degree of subluxation. 3. Fusion of the atlanto-axial complex or of the occipito-atlanto-axial complex is indicated only in patients with progressive neurological signs and in those suffering from acute neurological episodes. 4. Difficulty in obtaining fusion with cancellous bone grafts alone was encountered and we recommend wiring of the laminae C.1 to C.2 in addition

Permanent patellar subluxation is treated with surgeries such as proximal realignment and distal realignment, however, it is difficult to cure this condition by using any methods. We performed mobile-bearing total knee arthroplasty (TKA) in a case of severe knee osteoarthritis complicated with permanent patellar subluxation since childhood, and obtained good results without performing any additional procedures. The patient was an 82-year-old woman with severe pain in the left knee. During the initial examination, the range of motion of the left knee joint was -10°of extension to 140°of flexion, and the Japanese Orthopaedic Association (JOA) score for knee osteoarthritis was 40 points (maximum score: 100). Preoperative radiographs showed a varus deformity in the left lower extremity with a femorotibial angle (FTA) of 188°, the axial view showed luxation of the patella. We performed TKA using a mobile-bearing implant. Intraoperative findings revealed that the central articular surface of the distal femur had disappeared, and that the patellar articular surface was concave and dome-shaped. The lateral patellofemoral ligament was released; this procedure was identical to that performed in conventional TKA. Postoperative radiographs showed good alignment, with an FTA of 173°. In the axial view, the patella was located in a reduced position at any angle of knee joint flexion. The postoperative range of motion of the left knee joint was 0°of extension to 130°of flexion. The patient was able to walk without the support of a T-shaped cane. There are many surgical treatments for permanent patellar subluxation. The appropriate treatment is selected according to the type and seriousness of the dislocation and the age of the patient. From the findings of the present case, we believe that in a case of knee osteoarthritis complicated with permanent patellar subluxation, surgery performed using a mobile-bearing implant would eliminate the necessity of performing additional proximal realignment and distal realignment

Background: Recurrent peroneal tendon subluxation is uncommon. We report the results of a delayed anatomic repair using suture anchors. Using a case series we tested the null hypothesis that there are no differences between pre- and post-operative status following anatomical repair of the superior peroneal retinaculum. Methods: In the period 1996 to 2001, we operated on 14 patients (all males; average age 25.3 ± 6.3 years, range 18–37) with traumatic recurrent unilateral peroneal tendon subluxation, with a followed up of 38 ± 3 (range 22 to 47) months. Results: No patient experienced a further episode of peroneal tendon subluxation, and all had returned to their normal activities. Maximum calf circumference, functional ability, peak torque, total work and average power of plantar flexion were always lower in the operated leg, but the differences did not reach statistical significance. The AOFAS Ankle-Hindfoot Scale increased significantly from 54.3 ± 11.4 to 94.5 ± 6.4 (p = 0.03), with five patients reporting a fully normal ankle. Conclusion: If an anatomic approach to treating the pathology is utilised, reattachment of the superior retinaculum is a most appropriate technique. It returns patients to a high level of physical activity, and gives high rate of satisfactory results both objectively and subjectively. Randomised control trials may be the way forward in determining the best surgical management method. However, the relative rarity of the condition and the large number of techniques make such a study difficult

1. Four patients with tetraplegia from rheumatoid subluxation occurring in the lower cervical spine are described and the common features are noted. 2. Compression appeared to be responsible for the cord damage, although it was not necessarily directly related to vertebral subluxation. The lesions causing the compression were varied. 3. Forcible attempts to reduce vertebral subluxation may be harmful. Two patients were improved by posterior decompression. 4. A suggested programme for the treatment of such patients is outlined

Anterior subluxation of the cervical spine from flexion-rotational violence is often overlooked. Either radiography is omitted or the slight displacement visible on the films is not recognised. A method for recognising these injuries is suggested. Five cases are described showing that in these subluxations the soft-tissue damage is severe, that late increasing displacement can occur, with varying neurological sequelae, and that instability can persist indefinitely. Four of the patients required stabilisation by operation, in contrast with complete dislocations in which 80 to 90 per cent fuse spontaneously

Traumatic atlanto-axial subluxation is a rare injury which may not be revealed on routine radiographs, especially when there is muscle spasm. We report on seven patients with atlanto-axial subluxation as a result of neck injury; only two of them had significant head injuries. Three patients presented with a neurological deficit attributable to the injury, one immediate and two with delayed onset. Traumatic atlanto-axial instability, occurring in an otherwise healthy patient, has a potential for neurological disaster; early consideration of operative treatment is indicated

Aims

Acetabular edge-loading was a cause of increased wear rates in metal-on-metal hip arthroplasties, ultimately contributing to their failure. Although such wear patterns have been regularly reported in retrieval analyses, this study aimed to determine their in vivo location and investigate their relationship with acetabular component positioning.

Objective: Ex vivo studies have suggested that cartilage contact areas and pressure are of high clinical relevance in the ethiology of osteoarthritis in patients with patellar subluxation. The aims of this study were therefore to validate in vivo measurements of contact areas with 3D open magnetic resonance imaging (MRI), and to study knee joint contact areas in patients with patellar subluxation at different angles of knee flexion in comparison with healthy subjects. Methods: 3D-MR image data sets of 12 healthy volunteers and 8 patients with patellar subluxation were acquired using a standard clinical (1.5T) and an open (0.2T) MRI scanner. We compared femoro-patellar and femoro-tibial contact areas obtained with two different sequences from open MRI [dual-echo-steady-state (DESS) and fast-low-angle-shot (FLASH) sequences] with those derived from standard clinical 1.5 T MRI. We then analyzed differences in joint contact areas between healthy subjects and patients with patellar subluxation at 0, 30 and 90 of knee flexion using open MRI. Results: The correlation of the size of contact areas from open MRI with standard clinical MRI data ranged from r = 0.52 to 0.92. Open-MRI DESS displayed a smaller overestimation of joint contact areas (+21 % in the femoro-patellar, +12% in the medial femoro-tibial, and +19% in the lateral femoro-tibial compartment) than FLASH (+40%, +37%, +30%, respectively). The femoro-patellar contact areas in patients were significantly reduced in comparison with healthy subjects (− 47% at 0, − 56% at 30, and − 42% at 90 of flexion; all p < 0.01), whereas no significant difference was observed in femoro-tibial contact areas. Conclusions: Open MRI allows one to quantify joint contact areas of the knee with reasonable accuracy, if an adequate pulse sequences is applied. The technique permits one to clearly identify differences between patients with patellar subluxation and healthy subjects at different flexion angles, demonstrating a significant reduction and lateralization of contact areas in patients. In the future application of this in vivo technique is of particular interest for monitoring the efficacy of different types of surgical and conservative treatment options for patellar subluxation

Ankylosing spondylitis (AS) is a progressive multisystem chronic inflammatory disorder. The hallmark of this pathological process is a progressive fusion of the zygapophyseal joints and disc spaces of the axial skeleton, leading to a rigid kyphotic deformity and positive sagittal balance. The ankylosed spine is unable to accommodate normal mechanical forces, rendering it brittle and susceptible to injury. Traumatic hyperextension injury of the cervical spine leading to atlantoaxial subluxation (AAS) in AS patients can often be fatal. We report a non-traumatic mechanism of injury in AS progressing to AAS attributable to persistent hyperextension, which resulted in fatal migration of C2 through the foramen magnum. Cite this article: Bone Joint J 2013;95-B:206–9

Introduction. Clinical observations suggest mid-flexion instability may occur more commonly with rotating platform (RP) total knee arthroplasty (TKA), including increased revision rates and patient-reported instability and pain. We propose that increased gap laxity leads to liftoff of the lateral femoral condyle with decreased conformity between the femoral component and polyethylene (PE) insert surface leading to PE subluxation or dislocation. The objectives of this study were to define “at risk” loading conditions that predispose patients to PE insert subluxation or spinout, and to quantify the margin of error for flexion/extension gap laxity in preventing these adverse events under physiologic loading conditions. Methods. Biomechanical testing was performed on six fresh frozen cadaveric knees implanted with a posterior stabilized RP TKA using a gap balancing technique. Rotational displacement and torque were measured over time, while stiffness, yield torque, max torque and displacement were calculated using a post-processing, custom MatLab code. Revision with varying size femoral components (size 3–6) and PE insert thicknesses (10–15mm), by downsizing one step, were used to create a spectrum of flexion/extension gap mismatch. Each configuration was subjected to three loaded testing conditions (0°, 30° and 60° flexion) in balanced and eccentric varus loading, known to represent daily clinical function and “at risk” circumstances. Results. PE insert rotational instability was primarily determined by conformity and contact area between the femoral condyle and the upper surface of the PE insert. In this RP design, contact area is known to decrease with flexion greater than 35°, which predisposed to abnormal motion of the femur on PE insert (Figure 1). Under all flexion/extension gap testing conditions, PE insert rotational displacement significantly decreased with increasing knee flexion (differences ranged from 0.42 to 1.01cm, p<0.05), confirming that decreased conformity allows unintended motion to occur on the upper rather than the lower insert surface, as kinematically designed. This decrease in insert rotation was further exacerbated with eccentric medial-sided loading (differences ranged from 0.77 to 1.18cm, p<0.05). Yield torque (19.66±6.79N-m, p=0.033) and max torque (19.76±5.93N-m, p=0.014) significantly increased with increasing flexion from 0° to 60° under gap balanced conditions. Yield torque significantly decreased with greater flexion gap laxity at 60° of flexion (−24.82±5.96N-m, p=0.004). The depth of the lateral PE insert concavity (1.7–3.6mm) varied with insert size and thickness and determined femoral condylar capture. The lateral insert concavity defines a narrow margin of error in flexion/extension gap asymmetry leading to rotational insert instability, especially in smaller sized knees (size 3) where the jump height (1.7mm) is less than the insert sizing increment of 2.5mm. Conclusions. Contact area is known to decrease with flexion greater than 35° in this TKA-RP design. Flexion gap laxity further increased the risk of unintended top-side rotation of the femur on the insert, especially with increasing flexion and smaller components. In RP-TKA, in addition to medial-lateral gap symmetry and flexion-extension balance, a snug flexion gap with less than 2mm lateral laxity is critical to avoid insert instability and condylar escape with insert subluxation. For any figures or tables, please contact authors directly

1. Nineteen patients with classical rheumatoid arthritis complicated by severe subluxation of the cervical spine are reported. 2. Thirteen patients had atlanto-axial subluxation. This was the only level ofinvolvement in ten. 3. The next most frequent level to be involved was C.4-5. This occurred in five patients. 4. Eleven patients required surgery for symptoms or signs of spinal cord compression or vertebral artery insufficiency. 5. Operations included six posterior fusions, three anterior fusions and two laminectomies. 6. The differential diagnosis, the radiological findings, the indications for surgery and the results of treatment are discussed