Purpose. In vivo comparative gap measurements were performed in 3 different patella positions (reduced, subluxated and everted) using offset-type-force-controlled-spreader-system. Methods. Prospectively, 50 knees were operated by TKA using a navigation-assisted gap balancing technique. The offset-type-force-controlled-spreader-system was used for gap measurements. This commercially-available instrument allows controllable tension in patella reduced position. The mediolateral gaps of knee extension (0°) and flexion (90°) angle were recorded in 3 different patella positions; reduced, subluxated and everted. Any gap differences of more than 3 mm were considered as a meaningful difference. Correlation between the difference with the demographic data, preoperative radiologic alignment and intraoperative data was analyzed. For statistical analysis, ANOVA and Pearson correlation test were used. Results. The gaps in patella eversion demonstrated smaller gaps both in knee extension and flexion position compared to the gaps of patella reduction position. The amount of decreased gaps was more definite in knee flexion position. Statistically significant difference were observed for the lateral gap of patella eversion compared to gap of patella reduction in knee flexion position (p<0.05). There were notable cases of variability in knee flexion position. Significant portion 12 (24%) knees of patella subluxation and 33 (66%) knees of patella evertion demonstrated either increased or decreased gaps in knee flexion position compared from the gaps of patella reduction position. Conclusion. The gaps in patella eversion demonstrated smaller gaps both in knee extension and flexion position compared to the gaps of patella reduction position. The amount of decreased gaps was more definite in knee flexion position. Therefore, the intraoperative patellar positioning has influence on the measurement of the joint gap. Keeping the patella in reduced position is important during gap balancing

Arthroscopic intervention for early symptoms of arthrosis of the knee was a well-established procedure until Moseley cited his study showing no difference in outcomes when compared to “sham” surgery. Now there is no opportunity for reimbursement with arthroscopic debridement unless mechanical internal derangement can be documented. There are, however, several specific lesions of arthrosis which respond well to arthroscopic intervention and are reimbursed by third party payers. Arthroscopic three compartment microfracture with non-weight bearing and passive motion for eight weeks post- op has significantly relieved symptoms. Second look biopsies have confirmed type II hyaline cartilage and increased joint interval. Proper patient selection is paramount and guidelines will be discussed. Isolated severe patellofemoral arthrosis with patella subluxation responds to arthroscopic patella lateral facetectomy. Jones has reported significant pain relief up to two years with this excellent option for a difficult patient problem. The technique and results will be presented in detail. Loss of terminal extension in the arthritic knee can accelerate deterioration and force earlier decision for TKA. Parson's third tubercle is an osteophyte that forms just anterior to the ACL insertion on the tibia and is the frequent cause of extension loss. Arthroscopic resection of the tubercle results in increased extension and diminishes the stress concentration assuring better longevity for the native knee. The diagnostic characteristics, resection techniques and results of the Dallas series will be presented

Purpose of Study:. Various techniques have been described and are still used for treating recurrent dislocation of the patella when conservative measures fail. Among them are distal, proximal and combined realignment techniques and lateral releases. Since being shown proof of the biomechanical importance of the medial patellofemoral ligament (MPFL) in patellofemoral instability, the reconstruction of the MPFL has gained in popularity. The objective of this paper is to present a case series with preliminary clinical results using the gracilis tendon to reconstruct the MPFL. Method:. Between 01/07 and 03/11 23 knees in 21 patients underwent reconstruction of the MPFL.4 of these patients had had previous surgery. Preoperatively the Caton Deschamps ratio using plain x-rays was worked out and the TT/TG distance was measured using CT scanning. Using these measurements as a guideline, 7 cases underwent a tibial tubercle transfer as an additional procedure. In 6 of the cases an additional cartilage procedure was required. The technique was simplified using intra-operative x-rays to achieve anatomical tunnel placement. Results:. The Tegner Activity Score was used to evaluate the patients preoperatively and at a minimum of 6 months postoperatively. The scores improved on average from 3,6 to 7,4. One patient had an extensor lag of 10 degrees at 3 months. This had normalised by 6 months. One patient had recurrence of her instability and required a revision MPFL reconstruction using an allograft. One patient had recurrent episodes of patella subluxation but no overt dislocation. Conclusion:. This case series gave good functional results using the Tegner Activity score. The procedure of MPFL reconstruction was effective in stabilising the patellae and in improving the symptoms of patellofemoral instability

Purpose of the study. To determine the outcome after the Semi-tendinosis tendon was used in reconstruction of the Medial Patella-femoral ligament using a fixed dynamic stabilising structure. Method. The Adductor Magnus tendon insertion at the Adductor tubercle of the medial femoral condyle was used as a dynamic and fixed stabilising point preventing patella subluxation. This is a constant landmark in most patients and eliminates the need to find the isometric stabilisation point of the Medial Patella-femoral ligament. The Semi-tendinosus tendon was routed from its distal tibia attachment through a drill hole in the patella from distal to proximal. It was then transferred sub-vastus around the Adductor Magnus femoral attachment and sutured back onto itself at the inferior patella pole. It was tensioned at 30 degrees of knee flexion. Between 2004 and 2011 forty knees were reconstructed using the Semi-tendinosus tendon combined with an extra-synovial lateral release. All had failed conservative therapy for repeated patella instability. Post-operatively the patients followed a strict rehabilitation protocol. At follow-up the patients were questioned for any symptoms of patella instability or dislocation. Any complications of the surgery were documented. Patients were examined for any signs of patella apprehension or abnormal patella tracking. Results. The male to female ratio was 2:3. The mean age was 26 (range13 to 33). The mean follow- up was 44 months. To date no recurrence of instability was noted. Within as early as 4 weeks post-surgery a reduction of patella apprehension was noted in all patients. 90% of patients were able to return to an active life-style. No serious complications were documented. Conclusion. Transferring Semi-tendinosus around the fixed, dynamic distal insertion point of Adductor Magnus provides good results in the medium term and is a technique that may be combined with distal patella tendon realignment procedures. NO DISCLOSURES

Background. We would like to analyze the risk factors of no thumb test among knee alignment tests during total knee arthroplasty surgery. Methods. The 156 cases of total knee arthroplasty by an operator from October 2009 to April 2010 were analyzed according to preoperative indicators including body weight, height, degree of varus deformity, and patella subluxation and surgical indicators such as pre-osteotomy patella thickness, degree of patella degeneration, no thumb test which was evaluated after medial prepatella incision and before bone resection (1st test), no thumb test which was evaluated with corrective valgus stress (2nd test, J test), and the kind of prosthesis. We comparatively analyzed indicators affecting no thumb test (3rd test). Results. There was no relation between age, sex, and body weight and no thumb test (3rd test). Patellar sulcus angle (p = 0.795), patellar congruence angle (p = 0.276) and preoperative mechanical axis showed no relationship. The 1st no thumb test (p = 0.007) and 2nd test (p = 0.002) showed signifi cant relation with the 3rd no thumb test. Among surgical indicators, pre-osteotomy patella thickness (p = 0.275) and degeneration of patella (p = 0.320) were not relevant but post-osteotomy patellar thickness (p = 0.002) was relevant to no thumb test (3rd test). According to prosthesis, there was no signifi cance with Nexgen (p = 0.575). However, there was signifi cant correlation between Scorpio (p = 0.011), Vanguard (p = 0.049) and no thumb test (3rd test). Especially, Scorpio had a tendency to dislocate the patella, but Vanguard to stabilize the patella. Conclusions. No thumb test (3rd test) is correlated positively with 1st test, 2nd test, and post-osteotomy patella thickness. Therefore, the more patella osteotomy and the prosthesis with high affi nity to patellofemoral alignment would be required for correct patella alignment