stiff knee
TRANSCRIPT
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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
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)
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)
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)