Neuroma of the sural nerve as a complication of stripping of the small saphenous vein

From 1989 to 1996, 61 patients, including 66 knees, aged 8 to 62, were diagnosed as mediopatellar plica syndrome of knee after arthroscopic examination. Twenty-one cases were misdiagnosed as medial meniscal lesions before arthroscopic examination. Fifty-nine patients (64 knees) underwent arthroscopic resection of the plicae and 2 patients underwent opened resection. Fifty-nine cases had an average follow-up of seven months. Fifty cases (54 knees) of them showed excellent and good results.     

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The plicae are synovial septa remaining in adult life that existed in early fetal life. The suprapatellar plica separates the suprapatellar pouch from the knee joint. The plica syndrome has clinical significance, which has been occasionally overlooked, but the pathophysiology of symptomatic plicae may be hard to explain. To evaluate the clinical significance of the suprapatellar plicae, the authors reviewed 34 cases in 23 patients with vague pain around the knee and a total septum of the suprapatellar plica at arthroscopic examination from September 1991 to December 1993. The follow-up period was from 6 months to 2 years and 9 months. The most common presenting symptom was chronic mild knee pain, aggravated by prolonged squatting or standing, with other patients reporting recurrent swelling, instability, giving-way, or a feeling of snapping. The objective findings include palpable band on the superomedial side, audible snapping, and local tenderness, but there were no significant abnormal findings in the laboratory. The radiographic findings were few, with sclerosis of the articular surface of the patella in 2(6%), malalignment in 1(3%), and mild degenerative change in 4 cases(12%). Five of 11 patients evaluated by bone scan had increased uptake around the patellofemoral joint, and 7 of 13 knees had a relatively small suprapatellar bursa on conventional arthrogram or pneumoarthrogram. At arthroscopy, a suprapatellar plicae with complete septum was identified in 30 of 34 cases (88%) and associated lesions presented as meniscal tears, loose body, and discoid meniscus without tear. The complete plicae were surgically excised under arthroscopic control in 30 patients and the results were excellent in 22 patients (73%), good in 5 (17%), and poor in 3 (10%)at 17 months follow-up; there were no failures. In our opinion, the complete suprapatellar plica is clinically significant in patients who have equivocal diagnosis of knee problems and further studies of the pathophysiology of complete suprapatellar plica are needed.     

Benefit of uncooked cornstarch in the management of children with dumping syndrome fed exclusively by gastrostomy

PURPOSE: Our goal was to evaluate the diagnostic value of MRI in plica syndrome. METHOD: MR images of a patient group (n = 55) with arthroscopically confirmed pathologic mediopatellar plicae were retrospectively analyzed and compared with those of a control group (n = 100). We obtained axial multiplanar gradient-recalled (MPGR), axial T1-weighted, and sagittal T2-weighted MR images. MR images were assessed for the width and length of all medial plicae. RESULTS: In the diagnosis of plica syndrome, sensitivity and specificity were 73 and 78% on axial MPGR images, 71 and 83% on sagittal T2-weighted images, and 95 and 72% on combination of both images, respectively. The incidence of pathologic medial plica increased with a criterion of extension beyond the medial end of the patella on axial MPGR images. CONCLUSION: MRI is a useful screening method in the diagnosis of plica syndrome.     

Pulmonary embolism; lung scanning interpretation: about words

OBJECTIVE: The purpose of this study was to determine the prevalence and nature of a horizontal cleft in the posterior aspect of Hoffa's infrapatellar fat pad and to show pathologic processes involving this cleft. MATERIALS AND METHODS: Fifty consecutive MR imaging examinations of the knee were evaluated for the presence and appearance of a cleft in the infrapatellar fat pad. Examples of abnormalities involving the cleft were collected from additional MR studies. MR imaging, gross dissection, and histologic examination of a cadaveric knee were also performed to evaluate the anatomy and histology of the cleft. RESULTS: The cleft in the infrapatellar fat pad was revealed on MR imaging in 45 of 50 knees and had a variable shape, either linear (82%), pipe-shaped (7%), or globular-shaped (11%). Joint effusion or anterior cruciate ligament tear did not affect the appearance of the cleft. The cleft was located anterior to the distal insertion of the anterior cruciate ligament on the tibia. At gross dissection of the cadaveric knee, the roof of the cleft was formed by the ligamentum mucosum (infrapatellar plica), and the cleft was lined with synovium. The prospective evaluation of additional MR imaging examinations of the knee revealed pathologic entities of the cleft such as ganglion cysts, loose bodies, nodular synovitis, and amyloid. CONCLUSION: A horizontal cleft located in the posterior aspect of the infrapatellar fat pad is a common and normal MR imaging finding with a prevalence of 90%. The horizontal cleft is lined with synovium and its roof is formed by the ligamentum mucosum (infrapatellar plica). This cleft communicates with the knee joint. A distended cleft can form a prominent recess mimicking pathologic processes; conversely, disorders can arise in the cleft.     

The MR appearance of the infrapatellar plica

OBJECTIVE: Our purpose is to describe the MR appearance and clinical relevance of the infrapatellar plica of the knee and to assess possible imaging pitfalls resulting from lack of recognition of this normal structure. Seven patients--four from our institution and three from our teaching file from outside institutions--were selected because they displayed the imaging features of the infrapatellar plica. CONCLUSION: The infrapatellar plica is readily appreciated on sagittal MR images of the knee as a low-signal-intensity structure in the intercondylar notch just anterior to the anterior cruciate ligament (ACL). The infrapatellar plica is important to recognize for the following reasons: It may be confused with an intact ACL because of its proximity and similar signal characteristics; it may pose difficulty to the arthroscopist when attempting to move instruments from the medial to lateral compartments of the knee; it can block clear visualization of the ACL during arthroscopy; and it can impair retrieval of loose bodies in the intercondylar notch. Familiarity with the infrapatellar plica should allow one to differentiate this normal structure from other structures in the knee and aid in preoperative planning.     

Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup

Infrapatellar contracture syndrome is an uncommon but recalcitrant cause of reduced range of motion after knee surgery or injury. The results and conclusions presented here are based on a retrospective clinical study evaluating the long-term outcome in 75 patients who developed infrapatellar contracture syndrome. These 75 patients (76 knees) were evaluated at an average followup of 53 months after the index (inciting) procedure or injury. Comparing subgroups within the study population, factors that correlated with poorer results or more severe infrapatellar contracture syndrome were found to be acute anterior cruciate ligament repair or reconstruction, the use of patellar tendon autograft for anterior cruciate ligament reconstruction, nonisometric graft placement, multiple surgical procedures, use of closed manipulation, and the development of patella infera. We concluded that appropriate procedures can substantially increase the range of motion in patients with infrapatellar contracture syndrome. However, residual functional morbidity persists in many patients, and the outcome, as determined by subjective knee function scores, is only fair. The natural history of an anterior cruciate ligament-deficient knee appears to be more benign than the natural history of a knee that develops infrapatellar contracture syndrome.     

Small-diameter (2 mm) laparoscopy in the evaluation of liver disease

We report the case of a pathological mediopatellar plica found in the right knee of a 15-month-old infant girl. Flexion contracture of the knee was found to be 40 degrees. An arthroscopic view showed a large and thick voluminous mediopatellar plica. It was trapped between the patella and the medial femoral condyle and it was in tight contact with the medial facet of the patella at 40 degrees flexion in the knee, blocking further extension. A longitudinal groove was noted on the articular surface of the medial femoral condyle that looked as if it had another trochlea on arthroscopic view. The mediopatellar plica came into contact with the groove at 60 degrees flexion in the knee and it fitted precisely into the groove at further flexion. The pathological plica was resected arthroscopically, which resulted in approximately 10 degrees improvement in extension of the knee. Histological examination found hypertrophy and chronic nonspecific inflammation of the synovium. The patient was helped with range-of-motion exercise and quadriceps-strengthening exercise. At 27 months follow-up, the knee had gained full extension. This article reports that a pathological mediopatellar plica may develop in infants.     

Anterior knee laxity and loss of extension after anterior cruciate ligament injury

This study was performed to examine the relationship between knee extension loss and the length of time after injury. We also wanted to compare anterior laxity in anterior cruciate ligament-injured knees in the early and late stages of injury. Loss of knee extension was measured in 81 patients with anterior cruciate ligament injury using lateral radiography with the injured leg relaxed and elevated. Extension loss was defined as the difference in maximal extension angle between the injured and uninjured knees. Average loss of extension was 3.6 degrees in the 17 knees in which the anterior cruciate ligament had been torn 3 weeks or less before examination (the acute injury group) and 0.6 degree in the 64 knees in which the anterior cruciate ligament had been torn more than 3 weeks before examination (the chronic injury group). The extension loss in the acutely injured knees was significantly greater compared with that in the uninjured knees and in the chronically injured knees. Arthrometric measurements using the KT-1000 arthrometer were reliable to diagnose an acute tear. There was no correlation between the degree of extension loss and arthrometric anterior knee laxity measurements. In 12 patients, the initial extension deficit in the early stage of injury significantly resolved with time, and manual maximum arthrometric measurements of anterior knee laxity improved spontaneously with time.     

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5-8-year follow-up

We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3 degrees-5 degrees extension loss compared with the normal side was present in 20 knees (22%) and 6 degrees-10 degrees in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5 degrees. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible.     

Shy-Drager syndrome. Neuropathological correlation and response to levodopa therapy

Synovectomies of the knee joint that were performed during the years 1960-65 at the Rheumatism Foundation Hospital because of rheumatoid arthritis have been re-examined after the lapse of 9.5 years in 156 patients and 202 knee joints and 110 non-operated knee joints of the same patients. Track of motion was helped both in synovectomized and in control knees. Deficiency of extension decreased only in the synovectomized knees; track of motion of the knee was improved by the operation. Swelling and pain appeared less often in operated than in control knees. The patient's own assessment of the operating results was good in 71% and poor in 12% of the cases. Radiological deterioration continued during the follow-up period both in the operated and in the control knees, though it was more severe in the latter. There is a distinct negative correlation between severity of disease and the patients's ability to work. Within the limits of this survey it is not possible to prove that synovectomy halts the radiological destruction of the knee joint; it is mainly a question of a measure that retards the rate of deterioration. One of the chief advantages of synovectomy of the knee is that it helps the patient to live a normal life and makes it possible for him to participate in working life.     

The Rotaglide total knee arthroplasty. Prosthesis design and early results

The Rotaglide knee (Cozim Medical, UK) is a three-part knee containing a mobile polyethylene meniscal platform, imparting reduced loosening forces to the tibia. The femoral component design provides a high degree of congruency throughout the range of motion from 0 degree to 110 degrees, and both femoral and tibial components ensure minimal bone removal. The system is versatile, including a large number of component options, and it may be used in both primary and revision arthroplasties. The first results in 170 cemented knees (161 patients) with 2- to 5-year follow-up periods (average, 3.1 years) were very encouraging (excellent or good in 95% of knees, based on the British Orthopaedic Association knee assessment system). Poor results were seen only in revision cases. There have been no mechanical implant failures and no platform bearing dislocations, and the platforms continue to move as documented by postoperative roentgenograms, which show the metal markers of the platforms moving anteriorly in flexion and posteriorly in extension.     

Fibrous myopathy. A rheumatic complication of drug abuse

A progressive fibrous myopathy may result from chronic intramuscular drug abuse. This complication may mimic other rheumatic disorders and early recognition may prevent disability. The patient described here presented with fixed flexion and extension contracture of hips and knees, respectively, after abusing meperidine and other agents for 3 years. Soft tissues of thighs and buttocks were "wood hard," EMG showed absence of action potentials in affected muscles, and biopsy revealed extensive replacement of muscle with dense, acellular fibrous tissue. Possible mechanisms are discussed.     

Renal expression of parathyroid hormone-related protein (PTHrP) and PTH/PTHrP receptor in a rat model of tubulointerstitial damage

The effect of a meniscal bearing on knee laxity in anterior cruciate ligament-sacrificing total knee arthroplasty was evaluated in 7 cadaver knees using a knee testing device that measured knee flexion angle as well as laxity to medial-lateral, anterior-posterior [AP], and rotational loads. A standard fixed tibial component and mobile tibial components (AP sliding, rotationally sliding, and AP and rotationally sliding) were used to evaluate AP, rotational, and varus-valgus stability and maximal flexion and extension with the neutrally positioned and malrotated tibial tray. The AP movable components increased AP laxity, and the fixed component decreased rotational laxity significantly when compared with the normal knees. The rotationally movable components did not change knee laxities significantly even when the tibial tray was malrotated. No significant difference among the components was detected when the maximal flexion and extension angles were compared in the neutrally positioned tibial tray. Malrotation of the tibial tray decreased the maximal extension angle in the fixed component. This study showed that the rotationally movable component can achieve near-normal laxity regardless of tibial tray rotation, but AP mobility of the bearing produces AP laxity that could lead to implant failure.     

The estimation of efficacy of oral iron supplementation during treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing cardiac surgery

OBJECTIVE: Quantitative evaluation of radiographic methods proposed to improve the detection of joint space narrowing (JSN) in femorotibial osteoarthritis (OA). METHODS: Thirty-two consecutive patients with knee OA and five normal controls had three different weight-bearing radiographs of the knee: (1) anteroposterior film of both knees in full extension (extended knees), (2) anteroposterior film of one knee in extension while the patient was standing on the homolateral foot (standing on homolateral foot), (3) posteroanterior film of both knees flexed at 30 degrees (schuss view). Joint space was analyzed blind using both an evaluation of JSN with a six-grade scale (JSN score) and an image analyser computer measurement of the mean joint space width (mean JSW). The medial compartment of medial femorotibial OA knees, the lateral compartment of lateral femorotibial OA knees, as well as both compartments of control knees, were measured. Extended knee and schuss views were made 1 year later in 10 patients for the evaluation of sensitivity to change. RESULTS: The JSN scores +/- S.D. in schuss, standing on the homolateral foot and extended knee views were 2.75 +/- 1.31, 1.95 +/- 1.3 and 1.66 +/- 1.27, respectively. The mean JSW +/- S.D. in schuss, standing on the homolateral foot, and extended knee views were 2.9 +/- 1.9 mm, 3.5 +/- 1.6 mm and 3.8 +/- 1.5 mm, respectively. Changes in JSN scores and mean JSW with schuss view increased with OA severity. In controls, JSW of the medial compartment did not vary in the three views. JSW of the lateral compartment of controls was significantly larger in the schuss view. The change in JSW after 1 year was -0.41 mm (P = 0.02) in the schuss view and -0.17 mm (P > 0.05) in the extended knee view. CONCLUSION: The schuss view is suggested as the most accurate method for the evaluation of JSW in femorotibial OA.     

The plica mediana dorsalis of the dura mater and its relation to lumbar peridurography (canalography)

Lewit and Sereghy (1975) have expressed some doubts about the existence of the dorsal plica mediana and its relation to the median translucency regularly seen on peridurographic pictures made in the PA projection. The present paper reports the demonstration of the dorsal plica mediana in fresh anatomical preparations under conditions lowering the intradural pressure, and the relation of the plica to the peridurographical median translucency, shown on the basis of the injection into the lumbar peridural space of a gelatine solution containing India ink.     

Extensor mechanism reconstruction with an allograft after total knee arthroplasty

The authors report on a series of 15 knees in which an extensor mechanism allograft was used to treat a rupture of the patellar tendon associated with a total knee arthroplasty. Nine of the knees have greater than two-year follow-up evaluation (average, 4.1 years; range, 2.3-7 years). Postoperatively, the average flexion was 106 degrees. All but three patients achieved full passive extension. Six of the nine knees had no extensor lag. The average post-operative clinical score for the follow-up group was 78 points. Graft complications include one early graft rupture, one early quadriceps junction failure, and one patellar component loosening. One graft fractured after revision of a metal-backed patella.     

In vivo determination of patello-femoral separation and linear impulse forces

Problems associated with the patellofemoral joint account for nearly half of all total knee arthroplasty (TKA) revisions. Under in vivo conditions, we previously determined that TKA subjects experience patellofemoral separation while performing dynamic, weight-bearing activities. This study investigates the impulse loading conditions that may exist at the time the patella impacts the femur during knee flexion. Fifty-seven subjects (68 knees) performed three successive deep knee bends under fluoroscopic surveillance. Eleven subjects (14 knees) had a posterior cruciate retaining (PCR) TKA, 19 subjects (25 knees) had a posterior cruciate substituting (PS) TKA, 15 subjects (17 knees) had a normal knee, and 12 subjects (12 knees) had an anterior cruciate ligament deficient (ACLD) knee. Velocities of each subjects' patella relative to a fixed point on the tibia were used as input to a mathematical model incorporating the impulse-momentum equation. At full extension, 12 of 14 PCR knees, 11 of 25 PS knees, 1 of 12 ACLD knees, and none of the 17 normal knees exhibited patellofemoral joint separation. The maximum separation, detected in a PCR knee, was 12 mm. The relative force determined upon patellofemoral impact was minimal (1.0 N). Simulated walking conditions for each subject were then entered into the mathematical model at a rate of 100 Hz and the calculated patellofemoral impact forces ranged from 78 N to 213 N. Since impulse loading conditions occur over a very small period of time, it was concluded that capturing fluoroscopy images at a rate of 30 Hz was too slow. Under simulated walking conditions, the impact forces due to impulse loading could contribute to polyethylene failure if these conditions induce fatigue of the polyethylene.     

Androgen and glucocorticoid receptors in the stroma and epithelium of prostatic hyperplasia and carcinoma

OBJECTIVE: To determine the effect of full active and passive flexion and extension at physiological rates of movement on intraarticular pressure of the normal knee. METHODS: A 22 gauge Intracath catheter was introduced into 7 clinically normal knees and one abnormal knee in 4 subjects. Pressures were recorded via a pressure transducer and correlated with simultaneous recordings of flexion angle from an electronic goniometer while the subject's knees were traverse through active and passive horizontal flexion at a rate of 1 cycle/2 s. RESULTS: The technique produced 6 satisfactory records over mean active and passive flexion ranges of 135 degrees and 148 degrees. On passive movement, pressures remained negative through most of the cycle, rising to main maximum pressures of 10 mm Hg after about 110 degrees of flexion. On active movement, the most common result was a U shaped curve rising from negative in midflexion to positive on full flexion and extension. The mean maximum pressures recorded on active movement were 38 mm Hg on flexion and 18 mm Hg on extension. CONCLUSION: There is no linear correlation between flexion angle and pressure. Under dynamic conditions at zero gravity intraarticular pressure shows a moderate rise on full passive flexion and in most subjects a substantial rise on active flexion and extension. These differences are significant. The factor governing pressure is not the flexion angle but the accompanying soft tissue changes. Failure to use the full movement range could reduce the efficiency of trans-synovial flux.     

Neuropathy of the saphenous nerve as a cause of knee pain

Neuropathy of the infrapatellar branch of the saphenous nerve is a frequently overlooked cause of persistent medical knee pain. The author wishes to identify this as a distinct entity and to present five cases. All of these cases were caused by direct blows to the medial aspect of the knee, did not respond to conservative treatment, and were essentially cured via neurolysis or neurectomy of the infrapatellar branch. Nerve entrapment is a frequent cause of intractable symptomatology in various areas of the body. The most commonly recognized nerve entrapment condition is carpal tunnel syndrome. Another condition, saphenous nerve entrapment, is all too frequently overlooked and underdiagnosed.     

Discoid lateral meniscus in children. Long-term follow-up after total meniscectomy

We retrospectively reviewed the long-term results of total meniscectomy performed in seventeen knees (fourteen children) to treat a discoid lateral meniscus. The mean duration of follow-up was 19.8 years (range, 12.5 to 26.0 years). On the basis of the rating system of the International Knee Documentation Committee, seven knees were normal (grade A), six were nearly normal (grade B), three were abnormal (grade C), and one was severely abnormal (grade D) at the latest follow-up evaluation. Ten of the seventeen knees had clinical symptoms of osteoarthrosis. Radiographs were available for fifteen of the knees at the latest follow-up evaluation. Eleven of the treated knees could be compared with the uninvolved, contralateral knee. Ten knees had osteoarthrotic changes, such as flattening of the lateral femoral condyle, formation of a ridge along the lateral femoral condyle, and spurring and sclerosis of the tibial plateau. Osteochondritis dissecans developed in two knees, nine and twenty years after the initial meniscectomy.