Patella Baja amp Posterior Capsular Release

Dr Amite Pankaj

MS DNB MRCS Edin

Professor Orthopedics

University College of Medical Sciences and GTB Hospital

Delhi India

Knee StiffnessCommon Sense Tells ushellip

bull Restricted Flexion

ndash Anterior structures

bull Restricted Extension

ndash Posterior structures

ndash ldquoPatellar entrapmentrdquo

Flexion loss is better tolerated than extension loss

Stiff KneePatho-anatomy

bull Anterior Interval

bull Retinacula and gutters

bull Posterior Structures

bull Quadriceps Mechanism

Normal Knee Extension

bull Static Limitation

ndash Anterior Compression

bull Anteromedial Joint Surfaces and Fat pad

ndash Posterior Tension

bull CapsuleHamstringsGastroc

Anterior Interval

bull Anteriorly Infrapatellar fat pad

and patellar tendon

bull Posteriorly Anterior border of

tibia and transverse meniscal

ligament

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Knee StiffnessCommon Sense Tells ushellip

bull Restricted Flexion

ndash Anterior structures

bull Restricted Extension

ndash Posterior structures

ndash ldquoPatellar entrapmentrdquo

Flexion loss is better tolerated than extension loss

Stiff KneePatho-anatomy

bull Anterior Interval

bull Retinacula and gutters

bull Posterior Structures

bull Quadriceps Mechanism

Normal Knee Extension

bull Static Limitation

ndash Anterior Compression

bull Anteromedial Joint Surfaces and Fat pad

ndash Posterior Tension

bull CapsuleHamstringsGastroc

Anterior Interval

bull Anteriorly Infrapatellar fat pad

and patellar tendon

bull Posteriorly Anterior border of

tibia and transverse meniscal

ligament

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Stiff KneePatho-anatomy

bull Anterior Interval

bull Retinacula and gutters

bull Posterior Structures

bull Quadriceps Mechanism

Normal Knee Extension

bull Static Limitation

ndash Anterior Compression

bull Anteromedial Joint Surfaces and Fat pad

ndash Posterior Tension

bull CapsuleHamstringsGastroc

Anterior Interval

bull Anteriorly Infrapatellar fat pad

and patellar tendon

bull Posteriorly Anterior border of

tibia and transverse meniscal

ligament

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Normal Knee Extension

bull Static Limitation

ndash Anterior Compression

bull Anteromedial Joint Surfaces and Fat pad

ndash Posterior Tension

bull CapsuleHamstringsGastroc

Anterior Interval

bull Anteriorly Infrapatellar fat pad

and patellar tendon

bull Posteriorly Anterior border of

tibia and transverse meniscal

ligament

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Anterior Interval

bull Anteriorly Infrapatellar fat pad

and patellar tendon

bull Posteriorly Anterior border of

tibia and transverse meniscal

ligament

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Causes

bull Trauma

bull Previous Surgery

bull Hoffarsquos Syndrome

bull Immobilization

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Infra Patellar Contraction Syndrome (IPCS)

bull Paulos et al 1987

bull ldquoDense fibrosclerotic reactionrdquo around fat pad

leading to ldquoentrapment of patellardquo causing

loss of ldquoflexion and extensionrdquo

bull Contracture of PT Patella Baja

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

ldquoDoor-Jamrdquo Effect of Rigid Fat Pad

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Anterior Interval and Patella BajaPathogenesis

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

bull Anterior interval opens with extension and tightens during flexion

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Anterior Interval ScarringClinical Presentation

bull AKP

bull Fullness in anterior knee upon extension

Findings

bull Small flexion contracture

bull Decreased proximal excursion of patella

bull Loss of extension with ldquosoftrdquo end point

bull Positive Hoffarsquos test

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Radiological Findings

bull Milder Forms

bull Scarring of Anterior Interval on MRI

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Patella Baja

bull Caton-Dechamps (CD) Ratio

bull Insall-Salvati (ISR) Ratio

bull gt12 Patella Alta

bull lt06 Patella Baja

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Length of Patellar Tendon on MRI

bull lt25 cm

bull No proximalization

of TT

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

TreatmentPrevention

bull Alert Signals

ndash Flexed Knee Gait

ndash Worsening Pain

ndash Weakwasted quads

ndash Warm joint

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Objective Alerts on serial exams

ndash Restricted patellar mobility

ndash Downward migration of patella

ndash Worsening ROM

ndash Weak Quad Contractions

ndash Decreased upward mobility of patella on quad

contractions

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

ConservativeEarly Patella Infra and IPCS

bull Aggressive physical therapy

bull Patella mobilization

bull Prone Hangs

bull Night splints

bull Serial casting

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Surgical

bull Arthroscopic Anterior Interval Release

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Chronic Patella Baja

bull Rarely seen in isolation

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Patellar Tendon Lengthening

bull H Dejour and D Dejour

bull PT length lt 25cm

bull Z-plasty

bull Augmentation with SemiT or allograft

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Patellar Tendon Lengthening

Knee 2014 Mar21(2)605-8 doi 101016jknee201310006 Epub 2013 Oct 24Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograftJeong JS1 Wang JH2

Abstractbull Management of patella infera remains a difficult therapeutic endeavor

We report a case of a 21-year-old man who had development of patella infera and knee flexion contracture after a patella fracture Patella inferawas treated by patellar tendon lengthening and augmentation with a tibialis anterior tendon allograft fixed with bioabsorbable cross-pins The patient regained an anatomic patellar position and full range of motion at two years after surgery

Tibial Tubercle Transfer (Proximal)

Posterior Capsular Contracture

bull 5 degrees loss noticeable limp fatigue of quads and hamstrings

bull 10 degrees loss poorly tolerated

bull ldquoFirmrdquo end point indicate posterior capsule scarring

TreatmentEarly Conservative

bull Prone Hangs

bull Extension splints

bull Physical therapy

Arthroscopic Release

bull Posteromedial Release (Laprade 2008)

bull Posteromedial and posterolateral Release

(Mariani 2010)

Technical Issues

bull Establish Posterior portals

ndash MFC and PCL

ndash ACL and PCL

bull Posterior Trans-septalportal

bull Neurovascular injury

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Posterior Capsular Contracture

bull 5 degrees loss noticeable limp fatigue of quads and hamstrings

bull 10 degrees loss poorly tolerated

bull ldquoFirmrdquo end point indicate posterior capsule scarring

TreatmentEarly Conservative

bull Prone Hangs

bull Extension splints

bull Physical therapy

Arthroscopic Release

bull Posteromedial Release (Laprade 2008)

bull Posteromedial and posterolateral Release

(Mariani 2010)

Technical Issues

bull Establish Posterior portals

ndash MFC and PCL

ndash ACL and PCL

bull Posterior Trans-septalportal

bull Neurovascular injury

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

TreatmentEarly Conservative

bull Prone Hangs

bull Extension splints

bull Physical therapy

Arthroscopic Release

bull Posteromedial Release (Laprade 2008)

bull Posteromedial and posterolateral Release

(Mariani 2010)

Technical Issues

bull Establish Posterior portals

ndash MFC and PCL

ndash ACL and PCL

bull Posterior Trans-septalportal

bull Neurovascular injury

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Arthroscopic Release

bull Posteromedial Release (Laprade 2008)

bull Posteromedial and posterolateral Release

(Mariani 2010)

Technical Issues

bull Establish Posterior portals

ndash MFC and PCL

ndash ACL and PCL

bull Posterior Trans-septalportal

bull Neurovascular injury

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Technical Issues

bull Establish Posterior portals

ndash MFC and PCL

ndash ACL and PCL

bull Posterior Trans-septalportal

bull Neurovascular injury

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Laprade 2008

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Laprade 2008

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)

Take Homehellip

bull Limitation of extension

ndash Posterior contracture

ndash Anterior interval

bull Patella baja

ndash Proximalization of TT

ndash PT lengthening

bull Posterior capsular release

ndash Arthroscopic (neurovascular structures)