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The complex causes of patellofemoral disorders are most effectively identified through a systematic evaluation of a patient's lower-extremity alignment, patellar mobility, muscle flexibility, strength, and coordination as well as an assessment of soft-tissue and articular pain. By combining information from such an exam with a careful history and appropriate radiographic studies, the physician can make a specific diagnosis. This sets the stage for an optimal rehabilitation prescription, which usually will involve some combination of muscle flexibility and strength training, taping, orthoses, analgesics, and therapy with heat and ice. [ABSTRACT FROM AUTHOR]

Case: A 75-year-old woman status post total shoulder arthroplasty and posterior rib resection 29 years previously experienced a low-energy intrathoracic scapular dislocation (ISD). Closed reduction under anesthesia was unsuccessful, and she required open surgical repair performed by a novel modification of Kibler's technique for medial scapular muscle repair., Conclusion: This case is unique because increased range of motion after successful arthroplasty allowed her shoulder to flex forward enough to result in ISD. Successful surgical repair was performed by a technique previously not described., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C493)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Trochlear dysplasia is one of the main risk factors for recurrent patellar dislocation. The Dejour classification identifies four categories that can be used to classify trochlear dysplasia. The purpose of this study is to evaluate the inter- and intraobserver reliability of the Dejour classification for trochlear dysplasia. The hypothesis was that both intra- and interobserver reliability would be at least moderate., Methods: This is a cross-sectional, reliability study. Twenty-eight examiners from the International Patellofemoral Study Group 2022 meeting evaluated lateral radiographs of the knee and axial magnetic resonance images from 15 cases of patellofemoral instability with trochlear dysplasia. They classified each case according to Dejour's classification for trochlear dysplasia (A-D). There were three rounds: one with only computed radiograph (CR), one with only magnetic resonance imaging (MRI) and one with both. Inter- and intraobserver reliability were calculated using κ coefficient (0-1)., Results: The mean age of patients was: 14.6 years; 60% were female and 53% had open physis. The interobserver reliability κ probabilities were 0.2 (CR), 0.13 (MRI) and 0.12 (CR and MRI). The intraobserver reliability κ probabilities were 0.45 (CR), 0.44 (MRI) and 0.65 (CR and MRI)., Conclusion: The Dejour classification for trochlear dysplasia has slight interobserver reliability and substantial intraobserver reliability., Level of Evidence: Level I., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The scientific literature concerning the anatomy of medial soft-tissue stabilizers of the patella is growing exponentially. Much of the surgical literature has focused on the role of the medial patellofemoral ligament (MPFL) and techniques to reconstruct it, yet our understanding of its anatomy has evolved during the past several years. Given this, we report on the current understanding of medial patellofemoral anatomy and implications for reconstruction., Methods: Current and historical studies of medial patellar anatomy were reviewed, which include the MPFL and medial quadriceps tendon femoral ligament (MQTFL), as well as that of the distal medial patellar restraints, the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML). In addition to the reported findings, the authors' anatomic descriptions of each ligament during their dissections were identified and recorded., Results: Despite the name of the MPFL, which implies that the ligament courses between the femur and patella, recent studies have highlighted the proximal MPFL fibers that attach to the quadriceps tendon, known as the MQTFL. The MPFL and MQTFL have also been referred to as the medial patellofemoral complex, reflecting the variability in anatomical attachment sites. The MPFL accounts for only half of the total restraint to lateral patellar displacement, and the remaining contributions to patellar stability are derived from the combination of the MPTL and MPML, which function primarily in greater degrees of knee flexion., Conclusion: The understanding of the complexity of the medial patellar stabilizers continues to evolve. Although MPFL reconstruction is gaining wide acceptance as a procedure to treat patellar instability, it is important to recognize the complex and changing understanding of the anatomy of the medial soft-tissue stabilizers and the implications for reconstruction., Level of Evidence: V.

Background: Although patellofemoral instability is among the most prevalent knee disorders, the management of patients with this condition is complex and remains variable, given the lack of long-term, high-level clinical outcome studies to compare various operative and nonoperative modalities., Purpose: To discover a consensus within treatment controversies in patellofemoral instability among experienced knee surgeons with a specific interest in the patellofemoral joint., Study Design: Expert opinion; Level of evidence, 5., Methods: A 3-step modified Delphi technique was used to establish a consensus. A 34-question, case-based online survey regarding patellofemoral instability was distributed to all active members of the International Patellofemoral Study Group. Consensus statements were generated if at least 66% of the respondents agreed and then redistributed to the same panel. Modifications to the consensus statements were made based on the iterative feedback process until no discordance was encountered in the third stage., Results: Eight consensus statements were achieved. Nonoperative management is the current standard of care for a first-time dislocation in the absence of an osteochondral fragment or loose body requiring excision (100% agreement). In patients with a first-time dislocation with an operative osteochondral fracture requiring excision or repair, patellar instability should be addressed concurrently (89% agreement). Recurrent instability should be treated surgically, with most surgeons favoring medial reconstruction (77%-86% agreement). While there is general agreement that bony procedures should be performed to correct underlying bony deformities, there is no consensus regarding the most appropriate type of procedure performed. Lateral release should not be performed in isolation for the treatment of patellar instability (89% agreement)., Conclusion: Despite the consensus generated in this study, our current understanding remains limited by a lack of high-level evidence as well as the numerous complex variables influencing treatment decision making. High-quality, multicenter randomized controlled trials, particularly those directly comparing specific surgical treatment methods while controlling for underlying risk factors, are needed to address these areas of uncertainty.

Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.C.F. is a paid consultant for Breg and Flexion Therapeutics. This work was sponsored by grants from the American Orthopaedic Society for Sports Medicine (AOSSM), Patellofemoral Foundation (PFF), and Ferring Pharmaceutical.

We present a rational, scientific, low-risk approach to patellofemoral pain (anterior knee pain) based on an understanding of tissue homeostasis. Loss of tissue homeostasis from overload and/or injury produces pain. Bone overload and synovial inflammation are common sources of such pain. Chondromalacia and malalignment are findings that almost always do not need to be "corrected" to relieve pain. Patience and persistence in nonoperative care results in consistent success. Surgery should be rare and done only after extensive nonoperative management and in the setting of clearly defined pathology. Rational surgical treatment is explained in the context of restoring tissue homeostasis to relieve pain., Competing Interests: Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Background: An accurate physical examination of patients with patellar instability is an important aspect of the diagnosis and treatment. While previous studies have assessed the diagnostic accuracy of such physical examination tests, little has been undertaken to assess the inter- and intra-tester reliability of such techniques. The purpose of this study was to determine the inter- and intra-tester reliability of the physical examination tests used for patients with patellar instability., Methods: Five patients (10 knees) with bilateral recurrent patellar instability were assessed by five members of the International Patellofemoral Study Group. Each surgeon assessed each patient twice using 18 reported physical examination tests. The inter- and intra-observer reliability was assessed using weighted Kappa statistics with 95% confidence intervals., Results: The findings of the study suggested that there were very poor inter-observer reliability for the majority of the physical tests, with only the assessments of patellofemoral crepitus, foot arch position and the J-sign presenting with fair to moderate agreement respectively. The intra-observer reliability indicated largely moderate to substantial agreement between the first and second tests performed by each assessor, with the greatest agreement seen for the assessment of tibial torsion, popliteal angle and the Bassett's sign., Conclusions: For the common physical examination tests used in the management of patients with patellar instability inter-observer reliability is poor, while intra-observer reliability is moderate. Standardization of physical exam assessments and further study of these results among different clinicians and more divergent patient groups is indicated., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Unlabelled: The concept and need for a gender-specific or female-specific total knee prosthesis have generated interest and discussion in the orthopaedic community and the general public. This concept relies on the assumption of a need for such a design and the opinion that there are major anatomic differences between male and female knees. Most of the information regarding this subject has been disseminated through print and Internet advertisements, and through direct-to-patient television and magazine promotions. These sources and a recent article in a peer-reviewed journal, which support the need for a female-specific implant design, have proposed three gender-based anatomic differences: (1) an increased Q angle, (2) less prominence of the anterior medial and anterior lateral femoral condyles, and (3) reduced medial-lateral to anterior-posterior femoral condylar aspect ratio. We examined the peer-reviewed literature to determine whether women have had worse results than men after traditional TKAs. We found women have equal or better results than men. In addition, we reviewed the evidence presented to support these three anatomic differences. We conclude the first two proposed differences do not exist, and the third is so small that it likely has no clinical effect., Level of Evidence: Level IV, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.

Anterior knee pain is a frequent clinical problem. It provides a common challenge to diagnose and manage. Basic science studies have provided insight into the origin of anterior knee pain and refined understanding of the anatomy. Clinical evaluation has progressively focused on the contribution of the entire lower extremity to patellofemoral function. Nonsurgical management has been refined by the concept of the "envelope of function" and by increased understanding of the neuromuscular control of the knee. Indications for lateral release have been clarified and narrowed. Although anteromedial transfer of the tibial tuberosity is helpful in certain circumstances, reports of postoperative fracture have led to less aggressive rehabilitation protocols. Chondral resurfacing of the patellofemoral joint and patellofemoral arthroplasty are evolving. Emphasis should remain on nonsurgical management, which is sufficient in most patients.

Nonoperative treatment of patellofemoral pain has a long-standing tradition of success. I will discuss the scientific background and practical application of such treatment. Evaluation and treatment should include lower extremity flexibility, muscular control, and careful evaluation of tender structures. Avoiding pain during rehabilitation is important and suggestions for this are included in this review. Emphasis on accurate diagnosis, careful clinical evaluation, activity modification, flexibility, and strengthening in creating an effective program are discussed and the literature is reviewed. Most patients should go thorough nonoperative treatment before elective surgery for patellofemoral pain is prescribed.

Purpose: The purpose of this investigation was to determine current views regarding lateral release among experienced knee surgeons with a specific interest in the patellofemoral joint., Type of Study: Scientific survey., Methods: A questionnaire was developed and mailed to all members of an international group with a specific interest in disorders of the patellofemoral joint. Frequencies and percentages of responses were calculated for each question to determine surgeon consensus. We measured agreement among responses using the kappa statistic. This provided an indication of consistency for each question as well as correlation among the responses to different questions., Results: The survey response rate was 60%. Isolated lateral release was estimated to account for only 1 to 5 surgical cases per respondent per year, or 2% of cases performed annually. In the setting of arthroscopy or exploration, 74% of respondents believed that lateral release calls for specific informed consent. Strong consensus was found that objective evidence is needed to justify lateral release, but agreement was poor as to what clinical evidence provides the most appropriate indication for the procedure., Conclusions: Even among experienced knee surgeons with a special interest in diseases of the patellofemoral articulation, isolated lateral release is rarely performed. Strong consensus was found that isolated lateral release should not be undertaken without prior planning in the form of objective clinical indications and preoperative informed consent., Level of Evidence: Level V.

A clear understanding of the pathophysiology of anterior knee pain is inhibited by the use of imprecise, poorly defined, and often interchanged words, such as malalignment, patellar alignment, maltracking, subluxation, dislocation, and congruence. The literature is filled with articles regarding the diagnosis, "malalignment of the patella," most of which give no precise diagnosis. This article presents a definition of malalignment and a plea for rational descriptive and scientific analysis. Much of what is described is based on theory, not facts. These ideas are supported by clinical experience and logical analysis, but very little in the way of scientific data. Most of the data involve radiographic images, which present only one piece of the puzzle.

PURPOSE: As the use of soft-tissue anterior cruciate ligament (ACL) grafts, including hamstring grafts, has become more prominent and the benefits of aggressive rehabilitation have become clear, maximizing fixation with screw and spiked washers is important. Bicortical fixation may be superior. We were concerned about potential neurovascular risks and designed this study to define the posterior neurovasculature structures at risk when drilling for bicortical tibial screw fixation during ACL reconstruction. Type of Study: Consecutive sample. METHODS: We placed the tibial tunnel arthroscopically in 10 cadaveric knees using a standard tibial drill guide. Accurate tibial tunnel position was documented in each knee by lateral radiograph. A 4.5-mm bicortical drill hole was placed perpendicular to the tibial surface 1 cm distal to the tibial tunnel. The distances from the posterior tibial drill exit point to nearby neurovascular structures were measured with a caliper. RESULTS: The closest structure to the exit point was the bifurcation of the popliteal artery/vein (11.4 +/- 0.6 mm; range, 8.4 to 14.0 mm). The next closest was the anterior tibial vein (11.7 +/- 1.6 mm; range, 3.5 to 22.8 mm). The closest any individual hole came to a neurovascular structure was 3.5 mm from the anterior tibial vein. CONCLUSIONS: Bicortical drilling for fixation of soft tissue grafts appears reasonably safe. The structures at greatest risk for injury are the bifurcation of the popliteal artery/vein and the anterior tibial vein.

Accurate clinical evaluation of patients with patellofemoral disorders is the cornerstone of effective treatment. This article defines how a careful history and physical examination can direct strategies for nonoperative and operative management. A critical analysis of traditional methods of evaluation and a streamlined rational approach to clinical evaluation is presented. Key questions and important physical findings that affect treatment decisions are emphasized.

Chronic plantar fasciitis frustrates patients and treating physicians. Our hypothesis was that use of a dorsiflexion night splint for 1 month would effectively treat patients with recalcitrant plantar fasciitis. A 6-month randomized crossover study included 37 patients with chronic plantar fasciitis. Patients were treated with dorsiflexion night splints for 1 month. Group A wore splints for the 1st month and group B for the 2nd month. No splints were used in either group for the final 4 months of the study. No other medications, stretching, or strengthening exercises were prescribed. Eighty-eight percent of patients who completed the study improved. Eighty percent of the involved feet improved subjectively. Results of the AOFAS Ankle-Hindfoot Rating System and the Mayo Clinical Scoring System demonstrated significant improvement for both groups during the period of splint wear. Improvements were maintained at study completion. Response to splinting did not correlate with foot type, degree of obesity, or the presence of heel spur on radiographs. We believe dorsiflexion splints provide relief from the symptoms of recalcitrant plantar fasciitis in the majority of patients.

Success of meniscal repair with early or immediate motion depends on the ability of the suture fixation to withstand the loads applied. Vertical and horizontal mattress suture techniques were tested using 2-0 Ethibond, and 0-PDS and 1-PDS sutures (Ethicon, Somerville, NJ). Mulberry knot technique was tested with 0-PDS and 1-PDS sutures. Twenty menisci (60 sutures) were tested for each suture material. Sutures were placed 3 to 4 mm from the peripheral edge of the meniscus with double barreled cannulas for vertical and horizontal mattress techniques or a spinal needle for the mulberry knot technique, reproducing clinical techniques of meniscal repair. Mechanical testing of suture fixation was performed to failure at a rate of 10 mm/min on a MTS material testing system (MTS Systems Corp, Minneapolis, MN). Suture pullouts were reported as the load displacement to failure from the inner fragment only, because clinical failure would ensue should a suture pull through the inner fragment of a tear. Vertical mattress technique with 1-PDS suture had significantly greater load to failure than any other combination (P < .05). Analysis of variance showed that the vertical mattress technique had statistically superior pullout strength (P < .0001) compared with the horizontal mattress and mulberry knot techniques, which were statistically similar. There were significant differences (P < .0001) between suture types, with 1-PDS proving best compared with 0-PDS, which was stronger than 2-0 Ethibond. Selection of suture material had the greatest impact on vertical mattress load to failure and was not important to the strength of the other techniques.

Recently, there has been an emphasis placed on incorporating fundamental radiology in graduate level physical therapy curricula; however, the majority of practicing physical therapists never received formal radiology instruction. As health care changes, so must the role of the physical therapist. In a managed care environment, it is essential that physical therapists recognize basic radiographic findings and understand their clinical ramifications. The purpose of this article is to review the literature and provide commentary on avulsion fractures of the lateral tibial condyle, known as Segond fractures. Segond fractures typically occur by forced internal tibial rotation with the knee flexed. This mechanism placed tremendous force on the middle portion of the lateral capsule and associated meniscotibial ligament and results in a small bony avulsion. The Segond fracture is an important radiographic sign that is critical to recognize because it is generally associated with anterior cruciate ligament disruption.

Careful patient selection, accurate surgical technique, and careful postoperative rehabilitation are all equally important to success in lateral release surgery. Whether the surgery is performed by open or arthroscopic technique, one must release all layers of the retinaculum, spare the vastus lateralis, extend the release far enough distally, check intraoperative patellar mobility, and obtain absolute hemostasis. Postoperative rehabilitation must stress pain control, early quadriceps contraction, patellar mobility, and knee motion. With attention to these details, successful lateral release surgery is likely in most patients with pathologic lateral patellar tilt and minimal patellofemoral arthrosis.

Tensioning of the inferior glenohumeral ligament complex (IGLC) before arthroscopic repair is a critical step in restoring stability. This article describes a simple surgical technique to tension the IGLC percutaneously before arthroscopic fixation. This technique eliminates the need for grasping instruments and a second anterior portal.

All new patients who presented with knee problems were asked to fill out standard knee pain diagrams before being evaluated. Completed diagrams were not seen by the examining physicians. After obtaining the history and performing the physical examination, one of four physicians marked an identical diagram with the areas of tenderness. Ninety patients with a provisional diagnosis of patellofemoral pain completed 109 (19 bilateral) pain diagrams. Evaluation of the diagrams was quantitated by division of the diagrams into nine zones. The researcher grading the diagrams was blind to whether the diagrams were drawn by the patient or physician. Patients marked an average of 4.23 zones per knee compared with 2.66 zones for physicians. In 88% (96 of 109) of the knees, the physician diagram included all or some of the zones marked by the patients. Eighty-five percent of all zones marked by physicians were included in patient diagrams. Eighty-six percent of negative patient zones correctly predicted a negative examination. Overall frequency of positive findings in each of the nine zones was consistent between patient and physician diagrams. A physician can be confident that findings of tenderness will likely be within zones marked by a patient on a standard diagram of the knee. Pain diagrams facilitate proper diagnosis by correctly directing attention to areas of tenderness in a large percentage of cases and provide an inexpensive and highly useful prediction of areas of anterior knee tenderness in patients with patellofemoral pain.

A careful history and physical examination are the cornerstones of consistently successful diagnosis and treatment of anterior knee pain symptoms. Nonoperative treatment must be based on physical examination findings and should include both flexibility and strengthening. If an extended conscientious trial of nonoperative therapy fails to produce improvement, properly selected surgical procedures produce improvement in over 80% of cases. Realignment procedures, including lateral release, should only be proposed when malalignment can be documented. Although anterior knee pain has been called the "low back pain of the knee" by frustrated clinicians, effective treatment is likely when these principles are employed.

Paroxysmal supraventricular tachycardia (PSVT) can be reproducibly induced and terminated by critically timed atrial or ventricular depolarizations. In this study, noninvasive transcutaneous (external) cardiac pacing (NTCP) was compared to endocardial ventricular pacing for the termination and induction of PSVT. In 24 patients, either atrioventricular (AV) nodal reentrant tachycardia or AV reciprocating tachycardia was reproducibly terminated with either critically timed ventricular depolarizations or overdrive ventricular pacing from an endocardial right ventricular site. There were 32 trials of NTCP attempts to interrupt PSVT in the 24 patients. External pacing was successful at terminating PSVT in 23 patients and in 30 of 32 (94%) trials. In 20 patients, there were 26 trials of external pacing attempts to induce PSVT. External pacing initiated PSVT in 21 of 26 trials (81%). The pacing sequences used to induce and terminate PSVT with external pacing were copied from the endocardial sequences. The external pacing threshold averaged 77 +/- 22 mA but the current needed to terminate PSVT was about 1.5 greater than threshold at 117 +/- 27 mA. Serial external pacing studies were performed in seven patients. The thresholds for external pacing were similar from trial to trial as were the mode of termination and induction between the endocardial and external methods. External pacing can terminate most AV reciprocating tachycardias and many AV nodal reentrant tachycardias. It appears promising as a means of inducing PSVT. However, the high stimulation amplitudes needed will prohibit wide acceptance of external pacing for induction and termination of PSVT.

We determined whether ultraviolet (UV) visualization of tetracycline-labeled bone allows more complete excision of experimentally created physeal arrests while minimizing required bone resection. Lateral distal femoral growth arrests were surgically created bilaterally in eight 6-week-old New Zealand white rabbits, given 3 daily oxytetracycline doses (10 mg/kg); the animals were killed 6 weeks postoperatively. Femurs were excised and dissected free of soft tissue. Ten of 16 operated femurs randomized into two groups had consistent deformity. In group I, arrest was excised with a high-speed burr without, and, in group II, with ultraviolet visualization. In group II, metaphyseal bone and calcified arrest glowed brightly, contrasting well with the epiphyseal plate. All excised specimens were examined under x 9 magnification to assess remaining bone bridges. Excision defects were filled with modeling clay, which was then removed and weighed. Thorough excision was confirmed in each specimen. Resection was easier and less bone usually was resected in the UV group (difference not statistically significant). This technique would best be used in resection of arrests involving small physes such as the distal radius, in which maximal visualization and minimal resection are essential to preserve all possible growth potential. Tetracycline labeling and intraoperative UV visualization of fluorescence allows thorough excision of partial physeal arrest while minimizing required bone resection.

Effective treatment of patellofemoral malalignment is possible with precise diagnosis. This precision must begin with a thorough history and physical examination. Both nonoperative and operative treatment are guided by the specific patterns identified. Distal realignment procedures including anteromedial tibial tubercle transfer necessitate meticulous surgical technique to achieve maximal benefit with a low rate of complications.