5.0 (4) Question SessionPatella Fractures & Scaphoid Fractures . Orthobullets Team Pediatrics - Bipartite Patella ; Listen Now 15:15 . Team Orthobullets 4 Trauma - Patella Fracture; Listen Now 12:15 min. to prevent hardware failure in tension band construct: tension wire in 2 places to apply equivalent tension in both sides of construct, avoid overtensioning wire to prevent articular gapping or wire failure, avoid prominent cannulated screw tips that can cause wire failure, must remove devitalized fragments and loose bodies, perform with transosseous tunnels or suture anchors with knee in hyperextension, reattach as close to articular surface as possible, prevents patellar tilt and minimizes contact stresses, if necessary, reinforce with cerclage suture or wire from quadriceps tendon to tibial tubercle, remove all bony patellar fragments and loose bodies, restore integrity of extensor mechanism via imbrication of quadriceps and patellar tendons, medial and lateral retinacular repair remain essential, found to have better strength and outcomes, may avoid by performing sufficient imbrication, thought to be due to compromised soft-tissue envelope, improvement may be limited based on procedure performed, 0-22% of cases although catastrophic hardware failure is rare, may require revision ORIF, but if degree of reduction loss is small, may not affect union, thought to be due to excessive initial fracture displacement, can observe these, as most spontaneously revascularize by 2 years, may require I&D, possible hardware removal, usually resolves with aggressive physical therapy after fracture union, Post-traumatic patellofemoral osteoarthritis, osteonecrosis reported to occur in up to 25% but not found to affect clinical outcome, treated with partial or total patellectomy, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. government site. Patella alta has been shown to be associated with chondromalacia on the articular surface of the patella and pain. Anteroposterior . . 2016 Nov;474(11):2451-2461. doi: 10.1007/s11999-016-5027-5. re-rupture. An official website of the United States government. Normal patella variant representing a failure of fusion, considered a developmental variation of ossification, painful bipartite patella following injury, direct or indirect injury results in disruption of the fibrocartilaginous zone between the main patella and accessory fragment, fibrocartilaginous zone cannot heal by bony union, resulting in persistent pain, lack of arterial penetration from patella to osteochondral fragment, vastus lateralis contributes to traction force in fragment separation and nonunion. On sagittal MRI, the patellotrochlear index was used most; cutoff values ranged from <0.125 to 0.28. Konrads C, Schreiner AJ, Cober S, Schll D, Ahmad SS, Alshrouf MA. Diagnosis is confirmed radiographically with most commonly an unfused patella at the superolateral pole. The first is known as a traumatic patellar dislocation. Does Patella Tendon Tenodesis Improve Tibial Tubercle Distalization in Treating Patella Alta? Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. (OBQ12.145) Eleven studies used patellar tendon length and found it was increased (>52 mm to >56 mm). ratio of patellar tendon force to quads tendon force >1 at <45 and <1 at >45. 2022 Apr 13;14(1):66. doi: 10.1186/s13102-022-00462-w. Geraghty L, Zordan R, Walker P, Chao TW, Talbot S. Knee Surg Sports Traumatol Arthrosc. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Certified authentic Neapolitan Pizza by the Associazione Verace Pizza Napoletana, and multiple best pizza lists nationally. accounts for >50% of patella fractures in children, when patellar ossification is nearly complete, indirect injury caused by powerful contraction of the quadriceps muscle applied to a flexed knee, separation between the cartilage "sleeve" and main part of the patella and ossific nucleus, superior 3/4 of posterior surface covered by articular cartilage, articular cartilage thickest in body (up to 1cm), posterior articular surface comprised of medial and lateral facets, quadriceps tendon and fascia lata attach to anterosuperior margin, superficial layer formed from rectus femoris tendon, middle layer formed by vastus medialis and vastus lateralis tendons, deep layer formed by vastus intermedius tendon, patellar tendon attaches to inferior margin, derived from anastomotic ring originating from geniculate arteries, most important blood supply to the patella is located at the inferior pole, not associated with a direct blow to the knee, hemarthrosis of the knee joint is often present, high-riding patella or palpable gap at the distal end of the patella, indicates disruption of the extensor mechanism, difficulty with active extension of the knee, especially against resistance, small flecks of bone adjacent to superior or inferior pole, diagnosis may be missed because the distal bony fragment is not readily discernible on radiographs, may be useful for identifying a sleeve fracture when the diagnosis is not clear from the clinical and radiographic findings, repair torn medial/lateral retinaculum and/or quadricept/patellar tendon, Higher risk of complications associated with greater degree of, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Would you like email updates of new search results? sudden quadriceps contraction with knee in a flexed position (e.g., jumping sports, missing step on stairs) most ruptures occur with knee in flexed position. Epub 2022 Apr 19. Epub 2022 Aug 23. - See: - Lateral radiograph of the Knee. Please enable it to take advantage of the complete set of features! 2022 Jan;14(1):3-9. doi: 10.1111/os.13166. Patella Fractures are traumatic knee injuries caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism. Knee Surg Sports Traumatol Arthrosc. patella alta. The patella also helps guide the extensor mechanism, keeping it lined up in the middle of the front of the knee. Towson, MD 21204 tensile overload of the extensor mechanism. MeSH Treatment is observation and most often does not require treatment as the condition is typically asymptomatic. Bethesda, MD 20894, Web Policies Orthop Surg. Radiopaedia.org, the wiki-based collaborative Radiology resource Usually, young individuals, particularly women, suffer the consequences of this disorder [ 2 ]. Almost all dislocations are lateral in nature and are most easily reduced by simple . 2022. 2022 May;50(6):1627-1634. doi: 10.1177/03635465221089979. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. - Discussion: Patella Alta. Many children with CP depict progressive skeletal abnormalities .Amongst others, patella-alta, a vertically displaced kneecap, has been reported in 61-93% of ambulatory children with CP , .It is probably caused by elongated patellar-tendons and is often observed in children with crouch gait, a walking pattern during which knee loads are large . Find top doctors who treat Patella Dislocations near you in Vienna, VA. Book an appointment today! Epub 2018 Jun 11. Only rarely when it is symptomatic and nonoperative treatment fails does it require surgical excision. Before Patellar height as a determining factor. Both indices were seldom used on MRI; cutoff values were similar to those for conventional radiographs. (OBQ12.42) All evidence levels were included. This is most often the result of an . A Computational Study. SICOT J. Of 211 articles identified, 92 met the inclusion criteria for original study, and 28 for review. Patella Alta. - Subluxation of the Patella. The patella fits into a groove at the end of the femur (trochlear groove) and slides up and down as the knee bends and straightens. 10/15/2019. His knee is stable to varus and valgus at 30 degrees. Only 11 original studies proposed a critical patellar height as an indication for surgery; however, these studies mainly used CDI, and only 4 mentioned a desired postoperative patellar height after correction. Mayer C, Magnussen RA, Servien E, Demey G, Jacobi M, Neyret P, Lustig S. Am J Sports Med. Patella Fracture. Patellofemoral pain syndrome (PFPS) is a broad term used to describe pain in the front of the knee and around the patella, or kneecap. Physical exam is unremarkable with no signs of effusion or focal tenderness. Patellar Tendon Shortening for Treatment of Patella Alta in Skeletally Immature Patients With Patellar Instability. Femur-tibia angle and patella-tibia angle: new indicators for diagnosing anterior cruciate ligament tears in magnetic resonance imaging. Copyright 2022 Lineage Medical, Inc. All rights reserved. Associations. Rheumatology is an exciting and rapidly evolving medical specialty that treats a broad range of complex conditions. Patella Alta & Baja. It is typically asymptomatic, found incidentally, and does not require treatment. and transmitted securely. Dr. Nita Sumida is a rheumatologist. A patella dislocation occurs when the knee cap pops sideways out of its vertical groove at the knee joint. - Blackburne Method, - Treatment: - variations of more than 20% are considered abnormal; On examination, he has soft tissue swelling at the anterior knee and early ecchymosis formation. Because of the chronicity of the conditions rheumatologists treat, she is able to build long-term relationships with patients. Orthopaedic Specialists of North Carolina. In this clinical scenario, which of the following radiographs would warrant continued reassurance and observation? Orthobullets Team Knee & Sports patella baja. . A systematic review. 2018 Nov;138(11):1563-1573. doi: 10.1007/s00402-018-2971-4. Summary. Find a doctor near you. All rights reserved, Patella Fracture ORIF with Tension Band and K Wires, Question SessionPatella Fractures & Scaphoid Fractures. Epub 2016 Aug 30. The 'crossing sign' is present when the trochlear groove is in the same plane as the anterior border of the lateral condyle, suggestive of flattening. - Patella Infera. Patella Fractures are traumatic knee injuries caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism. Li Z, Li M, Du Y, Zhang M, Jiang H, Zhang R, Ma Y, Zheng Q. BMC Sports Sci Med Rehabil. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. The undersurface of the kneecap and the lower end of the femur are coated with articular cartilage, which helps in smooth movement of the knee joint. 1. Unfortunately, there is no generally accepted consensus on patella alta. Only 2 review studies suggested an ideal . - Discussion: - patella alta refers to an abnormally high patella in relation to femur; - may result in Subluxation and dislocation of patella; - Associated Conditions: His range of motion was full and no palpable crepitus over the patella was noted. 2022 Lineage Medical, Inc. Ortho Dx: Is this a patella alta or a patella baja? Patellar Sleeve Fractures are rare injuries seen in children between 8 and 12 years of age characterized by separation of the cartilage "sleeve" from the ossified patella. Wheeless' Textbook of Orthopaedics. Epub 2021 Dec 1. . - abnormal trochlea; Eleven studies used patellar tendon length and found it was increased (>52 mm to >56 mm). Search doctors, conditions, or procedures . Patellar Dislocation - Emergency Department. Telephone: 410.494.4994, dislocation or subluxation of the patella, Patella alta and patella infera. Patella alta and recurrent dislocation of the patella. Lateral radiograph of a 31-year-old woman's knee suggests a complete tear of the patella tendon or patella ligament. Bookshelf - length of patella ligament = diagonal length of patella; patella alta Insall-Salvati ratio >1 indicates disruption of patellar tendon patella baja Insall-Salvati ratio <1 indicates . Patellar subluxation, or a dislocation of the knee cap, requires a diagnosis and treatment from a doctor. eCollection 2021 Aug. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. This most often involves multiple factors, from acute trauma, chronic ligamentous laxity, bony malalignment, connective tissue disorder, or anatomical pathology. All rights reserved. A Sagittal Patellar Angle Linear Equation Reflecting Patellofemoral Kinematics: Evaluation of Patellar Height at any Degree of Knee Flexion Angle. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. McLean-Tysons. . doi: 10.1016/j.eats.2021.04.025. Please enter a valid 5-digit Zip Code. High tibial valgus osteotomy: closing, opening or combined? We systematically reviewed patella alta with respect to type of measurements, reported cutoff values, cutoff values for surgical correction, and proposed surgical techniques. Disclaimer, National Library of Medicine 674 plays. Cui LK, Kang K, Zheng XZ, Jiang SG, Huang WT, Gao SJ. Diagnosis is made with radiographs of the knee. Eighteen types of measurement methods with 27 different cutoff values were used to assess patella alta; these methods included lateral radiographs, sagittal MRI, radiographic ratios measured on MRI, and patellar tendon length. Patella Sleeve Fracture. When cartilage wears away, it becomes frayed and, when the wear is severe, the underlying bone may become exposed. 2021 Jul 20;10(8):e1979-e1984. 2022 Jul;30(7):2342-2351. doi: 10.1007/s00167-021-06813-3. PMC . FOIA 8600 Rockville Pike Patellofemoral arthritis occurs when the articular cartilage along the trochlear groove and on the underside of the patella wears down and becomes inflamed. Magnetic resonance imaging (MRI) for ligament reconstruction planning, Immobilize in 120 degrees of knee flexion for 24 hours and return-to-play in 2 weeks, Open reduction and internal fixation with interfragmentary screws with return-to-play in 5 months, Symptomatic treatment with return-to-play as tolerated, Long leg cast for 6 weeks with toe-touch weightbearing precautions with return-to-play in 2 months, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Bipartite Patella - Everything You Need To Know - Dr. Nabil Ebraheim. Only rarely when it is symptomatic and nonoperative treatment fails does it require surgical excision. Distalization of the Tibial Tubercle for Patellar Stabilization Combined With Medial Patellofemoral Ligament Reconstruction: Length of Distalization or Residual Patella Alta and its Affect on Outcome. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2022;8:36. doi: 10.1051/sicotj/2022037. Evaluation of patella height in native knees and arthroplasty: an instructional review. The site is secure. Inclusion criteria were original study or review articles, publication in peer-reviewed English-language journals between 2000 and 2017, and narrative description or measurement of human patellar height on plain radiographs or magnetic resonance imaging (MRI). Patella alta is a positional fault defined most simply as the superior displacement of the patella within the trochlear groove of the femur. - may result in Subluxation and dislocation of patella; - Associated Conditions: There are two types of patellar instability. - position of patella can best be determined on the Lateral Radiographw/ the knee flexed at 30 deg; 2014 Nov;472(11):3432-40. doi: 10.1007/s11999-014-3821-5. Patellar instability occurs when the kneecap moves outside of this groove. The knee cap or patella is the largest sesamoid bone in the body and one of the components of the knee joint, present at the front of the knee. He is able to continue playing for 10 more minutes before seeking medical attention. Diagnosis is made with radiographs of the knee. Their etiological role in patellar dislocation, chondromalacia, and apophysitis of the tibial tubercle, Patella alta and recurrent dislocation of the patella, Orthopaedic Specialists of North Carolina. treatment. In most cases, individuals are born with patella alta, but it can also develop secondary to a knee injury such as rupture of the patellar tendon. Patellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. Treatment is cylindrical casting for nondisplaced fractures with intact extensor mechanism. 2012 Feb;40(2):346-51. doi: 10.1177/0363546511427117. However, 12 (57%) of the 21 review studies that used ISI and 7 (39%) of the 18 review studies that used CDI did not report cutoff values. 2022 Lineage Medical, Inc. You may need a brace, crutches, physical therapy, or, in some cases, surgery. Characteristics/Clinical Presentation. Patella Alta, aka high riding patella, is where the kneecap sits higher than normal on the thigh bone. 110 West Rd., Suite 227 There is less than one-quartile of medial and lateral patellar translation with a negative "J" sign. Using the term patella alta, we performed a systematic literature search on PubMed. Summary. A 14-year-old high school running back strikes his left knee on an opposing players helmet during practice. A dislocated patella is painful and will prevent you from walking, but it's easy to correct and sometimes corrects itself. - dislocation or subluxation of the patella; 1 / 2. Epub 2011 Nov 22. compared with patella fractures, bipartite patellas: may have similar findings on contralateral knee radiographs (50%), accessory ossification center appears between 8-12 years, separate fragment attached to patella by fibrocartilaginous tissue, articular cartilage of patella is thickest in body (up to 1cm), blood supply to patella is predominantly from, most are asymptomatic and discovered incidentally, direct trauma (e.g. It's usually caused by force, from a collision, a fall or a bad step. The 92 original study articles defined patella alta mostly with imaging-based measurements (81.5%) and more rarely by description only (18.5%). Learn more . A bipartite patella is a congenital condition caused by failure of the patella to fuse. Patellar tracking refers to the dynamic relationship between the patella and trochlea during knee motion [ 1 ]. - patella alta refers to an abnormally high patella in relation to femur; Introduction. Patella alta may also occur as a result of spastic cerebral palsy 6. Authors Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this artile. Data Trace is the publisher of official website and that any information you provide is encrypted Patellar Sleeve Fractures are rare injuries seen in children between 8 and 12 years of age characterized by separation of the cartilage "sleeve" from the ossified patella. Data Trace Publishing Company Operative management is indicated for displaced fractures associated with disrupted extensor mechanism. Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism. HHS Vulnerability Disclosure, Help The Insall-Salvati index (ISI) was used more than the Caton-Deschamps index (CDI); cutoff values for patella alta varied from >1.2 to >1.5 for ISI and from >1.2 to >1.3 for CDI. However, 12 (57%) of the 21 review studies that used ISI and 7 (39%) of the 18 review studies that used CDI did not report cutoff values. Radiographs are shown in Figures A-C. What is the most appropriate next step in management. The lateral view can also allow assessment of trochlear dysplasia. Patella alta has also been implicated in patellar . Am J Sports Med. Bipartite Patella is a congenital knee condition caused by the failure of the patella to fuse and is often an incidental finding on radiographs. The patella sits at the front of the knee and acts as a fulcrum, increasing the moment arm of the quadriceps pull at the front of the knee to increase the efficiency and power of knee extension. Accessibility Several conditions are known to be associated with patella alta, including: idiopathic retropatellar pain 5. recurrent dislocation of the patella 2. chondromalacia patellae 2. knee joint effusion 2. Schmiesing A, Engelking M, Agel J, Arendt EA. - Insall's Ratio: B: patellar length . - hypoplasia of the vastus medialis, - Radiographs: Diagnosis is made clinically in the acute setting with a patellar dislocation with a traumatic knee effusion and in chronic settings with passive patellar . Presence of patella alta depends on the measurement method used. It is typically asymptomatic, found incidentally, and does not require treatment. Only 2 review studies suggested an ideal patellar height after surgery. The .gov means its official. This makes the knee less stable and prone to dislocation and anterior knee pain. Diagnosis is made with radiographs of the knee. A 19-year-old male complains of two week history of knee pain after falling during a college basketball game. cycling, hill climbing), aggravated by squatting, jumping, climbing stairs, localized tenderness over accessory fragment (typically superolateral patella), unusual patella prominence or palpable defect, may show displacement of the accessory fragment, consider radiographs of the contralateral knee for comparison, smooth edges (helps differentiate from fracture), weight-bearing skyline (squatting) view demonstrates, assessment of painful bipartite patella to determine if pain is attributable to the bipartite patella, equivocal radiographs with high suspicion for symptomatic bipartite patella, will clearly demonstrate fragment, but does not demonstrate edema, interposed tissue between accessory and main fragment, scalloped surface with numerous osteoclasts, rest, immobilization, NSAIDS, and physical therapy, generally, non-operative, symptomatic management is indicated for bipartite patella for at least 6 months, immobilization with the knee braced in 30 of flexion, non-operative management may be less successful in younger, athletic patients, possibly due to non-compliance, failed nonoperative treatment >6 months or in cases of a displaced fragment requiring reduction, direct trauma resulting in the onset of pain, or significant impairment in daily activities, most common treatment technique, typically good results, may lead to poor results if large, articular fragment due to patellofemoral incongruity, thought to lead to expedited recovery and avoids disrupting the quad tendon, limited evidence to support but good results in case reports, superolateral fragment (to remove the traction force of the vastus lateralis on the fragment), to avoid long lateral retinacular release, quicker recovery and less effusion noted in arthroscopic patients, limited support in the literature, controversial, due to excision of a large fragment or lateral retinacular release, may lead to patellofemoral degenerative changes, may require arthrocentesis following fragment excision, may see following lateral retinacular release, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Patella Fracture. Arthrosc Tech. Our review revealed many variations in patella alta definitions and descriptions, measurement methods, cutoff values, and treatment options. It is sometimes called "runner's knee" or "jumper's knee" because it is common in people who participate in sportsparticularly females and young adultsbut PFPS can occur in . Patellar instability, by definition, is a condition where the patella bone pathologically disarticulates out from the patellofemoral joint, either subluxation or complete dislocation. . Epub 2014 Jul 29. Insall-Salvati ratio > 1.0. indicates disruption of patellar tendon. A normal ratio is 1.0; a ratio greater than 1.2 suggests patella alta, while less than 0.8 suggests patella baja. He has a grade one Lachman examination and the medial tibial plateau is anterior to the medial femoral condyle upon a posteriorly directed force on the proximal tibia. Careers. Patellofemoral Pain Syndrome. Federal government websites often end in .gov or .mil. 1. Unable to load your collection due to an error, Unable to load your delegates due to an error. Different procedures were used to treat patella alta: tibial tubercle distalization with and without patellar tendon tenodesis, tibial tubercle distalization and medialization, and distal advancement of the patellar tendon. sharing sensitive information, make sure youre on a federal Diagnosis can be made clinically with the inability to perform a straight leg raise and confirmed with radiographs of the knee. Orthobullets Team Pediatrics - Bipartite Patella ; Listen Now 15:15 . Dislocation of the patella is a relatively common injury in the active adolescent population and usually a traumatic event associated with either an awkward fall or direct trauma to the patella itself. Treatment is cylindrical casting fornondisplaced fractureswith intact extensor mechanism. - lateral retinacular release is a poor choice in this condition. patella alta. The Insall-Salvati ratio was initially determined on a 30 flexed lateral knee x-ray and was later applied to sagittal MRI. The location you tried did not return a result. Patellar Sleeve Fractures are rare injuries seen in children between 8 and 12 years of age characterized by separation of the cartilage "sleeve" from the ossified patella. summary. aim beam 1.5cm distal to apex of patella true AP view should have symmetrical femoral and tibial condyles, fibular head bisected by the tibia, and visualization of intercondylar eminence in intercondylar fossa . Moving the bones along this rough surface may be painful. Treatment is cylindrical casting for nondisplaced fractures with intact extensor mechanism. In her free time, she enjoys playing tennis with . fall, kick to the knee), indirect trauma or overuse injuries (e.g. Appointments 216.444.2606. Distance lines are used to calculate Insall-Salvati ratio: A: patellar tendon length (TL): length of the posterior surface of the tendon from the lower pole of the patella to its insertion on the tibia. This site needs JavaScript to work properly. The https:// ensures that you are connecting to the Epub 2021 Nov 16. Clin Orthop Relat Res. Patellar dislocation is associated with increased tibial but not femoral rotational asymmetry. Does patella alta lead to worse clinical outcome in patients who undergo isolated medial patellofemoral ligament reconstruction? Clifford R. Wheeless, III, M.D. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. non-transtibial drilling techniques. greatest forces on tendon when knee flexion > 60 degrees. Clin Orthop Relat Res. patella fracture (usually postop during rehab), patellar tendon rupture. A bipartite patella is a congenital condition caused by failure of the patella to fuse. The 28 reviews described patella alta mostly with ISI (75%) or CDI (64%). Given its influence on patellofemoral loading/stress and patellar stability, however, we must strive to establish a consensus in the near future. due to fall, dashboard injury or other high energy mechanism, occurs from rapid knee flexion against contracted quadriceps muscle, often results in transverse fracture or inferior pole avulsion, patella is the largest sesamoid bone in the body, superior 3/4 of posterior surface covered by articular cartilage, articular cartilage thickest in body (up to 1cm), posterior articular surface comprised of two large facets (medial and lateral), each facet separated into smaller facets and divided by vertical ridge, occurs in approximately 2-3% of population, attaches approximately to upper 2/3 of medial patella, acts as primary ligamentous restraint to lateral patellar translation, quadriceps tendon and fascia lata attach to anterosuperior margin of patella, superficial layer formed from rectus femoris tendon, middle layer formed by vastus medialis and vastus lateralis tendons, deep layer formed by vastus intermedius tendon, formed by fascia lata, vastus medialis and vastus lateralis, contributes to strength of extensor mechanism, should be repaired at time of patellar fixation, derives from anastomotic ring originating from geniculate arteries, lies anterior to quadriceps tendon and posterior to patellar tendon, most important blood supply to the patella is located at the inferior pole, patella increases power and mechanical advantage of extensor mechanism by 30-50% by displacing it anteriorly away from the center of rotation, during knee flexion, patella experiences tension from quadriceps and patellar tendon and compressive loads across posterior patella, direct blow to knee or extensor mechanism injury, lacerations, abrasions in setting of open fracture, extensor mechanism and retinaculum disrupted, can aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain, saline load test can be performed to rule out concomitant knee joint involvement, obtained with knee in 30 of flexion if possible, degree of fracture displacement correlates with degree of retinacular disruption, indicates disruption of quadriceps tendon, articular step-off > 2-3 mm and displaced fracture gap > 3 mm dictate operative management, sagittal views particularly useful for visualizing distal pole comminution, change in operative plan in 50% of cases with CT, improved understanding of fracture patterns, particularly true in distal pole fracture patterns that are unappreciated on plain radiographs, smooth, regular borders seen on radiographs, caused by failure to unite secondary ossific nucleus, knee immobilized in extension (knee immobilizer, hinged knee brace or cast) with full weight bearing, intact extensor mechanism (patient able to perform straight leg raise), nondisplaced or minimally displaced fractures, active & active assist ROM at 1-2 weeks with resistance exercises beginning at 6 weeks, good or excellent results in >95% of patients with proper indications, open reduction and internal fixation (ORIF), extensor mechanism failure (unable to perform straight leg raise), may be preferred over tension band in cases of significant articular sided comminution, used alone or as supplement to primary fixation, high rates of union (>95%) despite technique, rates of nonunion higher with open fracture, symptomatic hardware requiring removal is common, WBAT in hinged knee brace with flexion limited to 30 for 4 weeks and progressed incrementally thereafter, comminuted extra-articular inferior pole fracture measuring <40% patellar height, patellar tendon should be advanced into defect on anterior surface of patella, decreases strength of extensor mechanism to increasing degree based on size of fragment removed, severe and extensive comminution not amenable to salvage, imbrication of quadriceps/patellar tendons, decrease in extensor mechanism strength >50%, midline longitudinal incision centered over patella, expose articular surface either through fracture site or retinacular rents, can alternatively perform lateral parapatellar arthrotomy and invert patella if retinaculum is not damaged or if better visualization of articular surface is desired, avoid extensive soft tissue dissection to preserve blood supply and viability of skin flaps, remove devitalized fragments and loose bodies, converts tensile forces generated by quadriceps complex at anterior surface into compressive forces at articular surface, difficult to manipulate and high re-operation rates due to painful hardware or wire migration, has 75% tensile strength of 18-gauge stainless steel wire but performs similarly clinically, lower rates of hardware removal when suture used, tension band using longitudinal 4.0 mm cannulated screws, biomechanically superior to tension band construct, versatile with multiplanar screw options available, effective in stabilizing distal pole fractures with comminution, less fracture gapping compared to tension band wiring, used alone or to augment additional fixation such as interfragmentary lag screws or tension band construct, important to place tension wire at superior aspect of construct where more soft tissue coverage is available, consider using braided suture as opposed to 18-gauge stainless steel wire, plates may have lower rates of hardware irritation compared to tension banding. can be made clinically with the inability to perform a straight leg raise and confirmed with radiographs of the knee. precise intra-operative measuring of tunnels and graft. 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