Anterior Knee Pain and Patellar Instability

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Anterior Knee Pain and Patellar Instability

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Vicente Sanchis-Alfonso (Ed)

Anterior Knee Pain

and Patellar Instability

With 240 Figures

including 108 Color Plates

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Vicente Sanchis-Alfonso, MD, PhD (Member of the International Patellofemoral Study Group/Member of the ACL Study Group)

Department of Orthopaedic Surgery Hospital Arnau de Vilanova

Valencia Spain

British Library Cataloguing in Publication Data Anterior knee pain and patellar instability

1. Patellofemoral joint - Dislocation 2. Patella -

Dislocation 3. Knee - Diseases 4. Knee - Wounds and injuries 5. Knee - Surgery 6. Pain - Physiological aspects

I. Sanchis-Alfonso, Vicente 617.5′82

ISBN-10: 1846280036

Library of Congress Control Number: 2005925983 ISBN-10: 1-84628-003-6 e-ISBN 1-84628-143-1 ISBN-13: 978-1-84628-003-0

Printed on acid-free paper

First published in 2003 as Dolor anterior de rodilla e inestabilidad rotuliana en el paciente joven. This English- language edition published by arrangement with Editorial Médica Panamericana S.A.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or trans- mitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency.

Enquiries concerning reproduction outside those terms should be sent to the publishers.

The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use.

Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case, the respective user must check its accuracy by consulting other pharmaceutical literature.

Printed in Singapore (SPI/KYO) 9 8 7 6 5 4 3 2 1

Springer Science+Business Media springeronline.com

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To my father. In memoriam (†)

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Foreword

Anterior knee pain is one of the really big problems in my specialty, sports orthopaedic surgery, but also in all other types of orthopaedic surgery. Many years ago Sakkari Orava in Finland showed that among some 1311 Finnish runners, anterior knee pain was the second most common complaint. In young school girls around 15 years of age, anterior knee pain is a common complaint. In ballet classes of the same age, as much as 60-70%

of the students complain of anterior knee pain. It is therefore an excellent idea of Dr.

Sanchis-Alfonso to publish a book about anterior knee pain and patello-femoral insta- bility in the active young.

He has been able to gather a group of extremely talented experts to help him write this book. I am particularly happy that he has devoted so much space to the non-operative treatment of anterior knee pain. During my active years as a knee surgeon, one of my worst problems was young girls referred to me for surgery of anterior knee pain. Girls that had already had 8-12 surgeries for their knee problem — surgeries that had ren- dered them more and more incapacitated after each operation. They now came to me for another operation. In all these cases, I referred them to our pain clinic for careful analy- sis, and pain treatment followed by physical therapy. All recovered but had been the vic- tims of lots of unnecessary knee surgery before they came to me.

I am also happy that Suzanne Werner in her chapter refers to our study on the per- sonality of these anterior knee patients. She found that the patients differ from a normal control group of the same age. I think this is very important to keep in mind when you treat young patients with anterior knee pain.

In my mind physical therapy should always be the first choice of treatment. Not until this treatment has completely failed and a pain clinic recommends surgery, do I think surgery should be considered.

In patello-femoral instability the situation is different. When young patients suffer from frank dislocations of the patella, surgery should be considered. From my many years of treating these types of patients, I recommend that the patients undergo an arthroscopy before any attempts to treat the instability begin. The reason is that I have seen so many cases with normal X-rays that have 10-15 loose bodies in their knees. If these pieces consist of just cartilage, they cannot be seen on X-ray. When a dislocated patella jumps back, it often hits the lateral femoral condyle with considerable force.

Small cartilage pieces are blasted away as well from femur as from the patella. If they are overlooked they will eventually lead to blockings of the knee in the future.

The role of the medial patello-femoral ligament can also not be overstressed. When I was taught to operate on these cases, this ligament was not even known.

I also feel that when patellar instability is going to be operated on, it is extremely important that the surgeon carefully controls in what direction the instability takes place. All instability is not in lateral direction. Some patellae have medial instability. If someone performs a routine lateral release in a case of medial instability, he will end up

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having to repair the lateral retinaculum in order to treat the medial dislocation that eventually occurs. Hughston and also Teitge have warned against this in the past.

It is a pleasure for me to recommend this excellent textbook by Dr.Vicente Sanchis- Alfonso.

Ejnar Eriksson, MD, PhD Professor Emeritus of Sports Medicine Karolinska Institute, Stockholm, Sweden

viii Foreword

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Preface

This book reflects my deep interest in the pathology of the knee, particularly that of the extensor mechanism, and to bring to the fore the great importance I give to the concept of subspecialization, this being the only way to confront the deterioration and medioc- rity of our speciality, Orthopaedic Surgery; and to provide our patients with better care.

In line with the concept of subspecialization, this book necessarily required the partici- pation of various authors. In spite of this, I do not think there is a lack of cohesion between the chapters. Now, there are certain variations in form, but not in basic content, regarding some topics dealt with by different authors. It is thus evident that a few aspects remain unclear, and the controversy continues.

With this work, we draw upon the most common pathology of the knee, even though the most neglected, the least known and the most problematic (Black Hole of Orthopaedics). To begin with, the terminology is confusing (The Tower of Babel). Our knowledge of its etiopathogeny is also limited, with the consequence that its treatment is of the most complex among the different pathologies of the knee. On the other hand, we also face the problem of frequent and serious diagnostic errors that can lead to unnecessary interventions. The following data reflect this problem: 11% of patients in my series underwent unnecessary arthroscopy, and 10% were referred to a psychiatrist by physicians who had previously been consulted.

Unlike other publications, this work gives great weight to etiopathogeny; the latest theories are presented regarding the pathogeny of anterior knee pain and patellar insta- bility, although in an eminently clinical and practical manner. In agreement with John Hunter, I think that to know the effects of an illness is to know very little; to know the cause of the effects is what is important. Nonetheless, we forget neither the diagnostic methods nor therapeutic alternatives, both surgical and non-surgical, emphasizing min- imal intervention and non-surgical methods. Similarly, much importance is given to anterior knee pain following ACL reconstruction. Further, the participation of diverse specialists (orthopaedic surgeons, physiotherapists, radiologists, biologists, patholo- gists, bioengineers, and plastic surgeons), that is, their multidisciplinary approach, assures us of a wider vision of this pathology. The second part of this monograph is given over to discussion of complex clinical cases that are presented. I reckon we learn far more from our own errors, and those of other specialists, than from our successes.

We deal with oft-operated patients with sequelae due to interventions, adequate or oth- erwise, but which have become complicated. The diagnoses arrived at are explained, and how the cases were resolved (“Good results come from experience, experience from bad results”, Professor Erwin Morscher).

Nowadays we are plunged into the “Bone and Joint Decade” (2000-2010). The WHO’s declared aim is to make people aware of the great incidence of musculoskeletal pathol- ogy and to reduce both economic and social costs. These same goals I have laid out in this book. Firstly, we are mindful of the soaring incidence of this pathology, and the impact on young people, athletes, workers, and the economy. Secondly, to improve prevention and diagnosis in order to reduce the economic and social costs of this

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pathology. The final objective is to improve health care in these patients. This, rather than being an objective, should point the way forward.

Anterior Knee Pain and Patellar Instability is addressed to orthopaedic surgeons (both general and those specialized in knee surgery), specialists in sports medicine and physiotherapists.

We feel thus that with this approach, this monograph will fill an important gap in the literature of pathology of the extensor mechanism of the knee. However, we do not intend to substitute any work on patellofemoral pathology, but rather to complement existing literature (“All in all, you’re just another brick in the wall”, Pink Floyd, The Wall). Although the information contained herein will evidently require future revision, it serves as an authoritative reference on one of the most problematic entities current in pathology of the knee. We trust that the reader will find the work useful, and conse- quently, be indirectly valuable for patients.

Vicente Sanchis-Alfonso, MD, PhD Valencia, Spain February 2005

x Preface

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Acknowledgments

I wish to express my sincere gratitude to my friend and colleague, Dr Donald Fithian, who I met in 1992 during my stay in San Diego CA, for all I learned, together with his help, for which I will be forever grateful; to Professor Ejnar Eriksson for writing the fore- word; to Dr Scott Dye for writing the epilogue, to Nicolás Fernández for his valuable photographic work, and also to Stan Perkins for his inestimable collaboration, without whom I would not have managed to realize a considerable part of my projects. My grat- itude also goes out to all members of the International Patellofemoral Study Group for their constant encouragement and inspiration.

Further, I have had the privilege and honor to count on the participation of outstand- ing specialists who have lent prestige to this monograph. I thank all of them for their time, effort, dedication, amiability, as well as for the excellent quality of their contribut- ing chapters. All have demonstrated generosity in sharing their great clinical experience in clear and concise form. I am in debt to you all. Personally, and on behalf of those patients who will undoubtedly benefit from this work, thank you.

Last but not least, I am extremely grateful to both Springer in London for the confi- dence shown in this project, and to Barbara Chernow and her team for completing this project with excellence from the time the cover is opened until the final chapter is presented.

Vicente Sanchis-Alfonso, MD, PhD

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Foreword

Ejnar Eriksson . . . vii

Preface

Vicente Sanchis-Alfonso . . . . ix Acknowledgments

Vicente Sanchis-Alfonso . . . . xi Contributors . . . xvii

Section I

Etiopathogenic Bases and Therapeutic Implications

1 Background: Patellofemoral Malalignment versus Tissue Homeostasis.

Myths and Truths about Patellofemoral Disease

Vicente Sanchis-Alfonso . . . . 3 2 Pathogenesis of Anterior Knee Pain and Patellar Instability in the Active Young.

What Have we Learned from Realignment Surgery?

Vicente Sanchis-Alfonso, Fermín Ordoño,

Alfredo Subías-López, and Carmen Monserrat . . . . 21 3 Neuroanatomical Bases for Anterior Knee Pain in the Young Patient:

“Neural Model”

Vicente Sanchis-Alfonso, Esther Roselló-Sastre,

Juan Saus-Mas, and Fernando Revert-Ros . . . . 33 4 Biomechanical Bases for Anterior Knee Pain and Patellar

Instability in the Young Patient

Vicente Sanchis-Alfonso, Jaime M. Prat-Pastor, Carlos M. Atienza-Vicente, Carlos Puig-Abbs,

and Mario Comín-Clavijo . . . . 55 5 Anatomy of Patellar Dislocation

Donald C. Fithian and Eiki Nomura . . . . 77 6 Evaluation of the Patient with Anterior Knee Pain

and Patellar Instability

Vicente Sanchis-Alfonso, Carlos Puig-Abbs,

and Vicente Martínez-Sanjuan . . . . 93

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7 Uncommon Causes of Anterior Knee Pain Vicente Sanchis-Alfonso, Erik Montesinos-Berry,

and Francisco Aparisi-Rodriguez . . . 115 8 Risk Factors and Prevention of Anterior Knee Pain

Erik Witvrouw, Damien Van Tiggelen, and Tine Willems . . . 135 9 Conservative Treatment of Athletes with Anterior Knee Pain.

Science: Classical and New Ideas

Suzanne Werner . . . 147 10 Conservative Management of Anterior Knee Pain:

The McConnell Program

Jenny McConnell and Kim Bennell . . . 167 11 Skeletal Malalignment and Anterior Knee Pain: Rationale,

Diagnosis, and Management

Robert A. Teitge and Roger Torga-Spak . . . 185 12 Treatment of Symptomatic Deep Cartilage Defects of the Patella

and Trochlea with and without Patellofemoral Malalignment:

Basic Science and Treatment

László Hangody and Ivan Udvarhelyi . . . 201 13 Autologous Periosteum Transplantation to Treat Full-Thickness

Patellar Cartilage Defects Associated with Severe Anterior Knee Pain

Håkan Alfredson and Ronny Lorentzon . . . 227 14 Patella Plica Syndrome

Sung-Jae Kim . . . 239 15 Patellar Tendinopathy: Where Does the Pain Come From?

Karim M. Khan and Jill L. Cook . . . 257 16 Patellar Tendinopathy: The Science Behind Treatment

Karim M. Khan, Jill L. Cook, and Mark A. Young . . . 269 17 Prevention of Anterior Knee Pain after Anterior Cruciate

Ligament Reconstruction

K. Donald Shelbourne, Scott Lawrance, and Ron Noy . . . 283 18 Lysis of Pretibial Patellar Tendon Adhesions (Anterior Interval

Release) to Treat Anterior Knee Pain after ACL Reconstruction Sumant G. Krishnan, J. Richard Steadman, Peter J. Millett,

Kimberly Hydeman, and Matthew Close . . . 295 19 Donor-Site Morbidity after Anterior Cruciate Ligament

Reconstruction Using Autografts

Clinical, Radiographic, Histological, and Ultrastructural Aspects

Jüri Kartus, Tomas Movin, and Jon Karlsson . . . 305

xiv Contents

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Section II

Clinical Cases Commented

20 Complicated Case Studies

Roland M. Biedert . . . 323 21 Failure of Patellofemoral Surgery: Analysis of Clinical Cases

Robert A. Teitge and Roger Torga-Spak . . . 337 22 Arthrofibrosis and Patella Infera

Christopher D. Harner, Tracy M. Vogrin,

and Kenneth J. Westerheide . . . 353 23 Neuromatous Knee Pain: Evaluation and Management

Maurice Nahabedian . . . 363

Epilogue

Scott F Dye . . . 373 Index . . . 375

Contents xv

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Contributors

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Håkan Alfredson, MD, PhD Associate Professor

Umeå University Sports Medicine Unit Department of Surgical and Perioperative Science Umeå, Sweden

Francisco Aparisi-Rodriguez, MD, PhD Department of Radiology

Hospital Universitario La Fe Valencia, Spain

Carlos M. Atienza-Vicente, Mch Eng, PhD

Orthopaedic Biomechanics Group Instituto de Biomecánica de Valencia (IBV)

Universidad Politécnica de Valencia Valencia, Spain

Kim Bennell, BAppSc(physio), PhD Centre for Health, Exercise and Sports Medicine

School of Physiotherapy

Faculty of Medicine, Dentistry and Health Sciences

University of Melbourne Australia

Roland M. Biedert, MD Member of the “International Patellofemoral Study Group”

Associate Professor, University of Basle Swiss Federal Institute of Sports Orthopaedics & Sport Traumatology Magglingen, Switzerland

Matthew Close, BA

Steadman Hawkins Sports Medicine Foundation

Vail, Colorado, USA

Jill L. Cook

Musculoskeletal Research Centre La Trobe University School of Physiotherapy

Melbourne, Australia

Mario Comín-Clavijo, Mch Eng, PhD Orthopaedic Biomechanics Group Instituto de Biomecánica de Valencia (IBV)

Universidad Politécnica de Valencia Valencia, Spain

Scott F. Dye, MD

Member of the “International Patellofemoral Study Group”

Associate Clinical Professor of Orthopaedic Surgery

University of San Francisco San Francisco, California, USA

Ejnar Eriksson, MD, PhD

Professor Emeritus of Sports Medicine Karolinska Institute

Stockholm, Sweden

Donald C. Fithian, MD Member of the “International Patellofemoral Study Group”

Kaiser Permanente Medical Group El Cajon, California, USA

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László Hangody, MD, PhD, DSc Uzsoki Hospital

Orthopaedic & Trauma Department Budapest, Hungary

Christopher D. Harner, MD Medical Director

Center for Sports Medicine

Department of Orthopaedic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA

Kimberly Hydeman, BA

Steadman Hawkins Sports Medicine Foundation

Vail, Colorado, USA Jon Karlsson, MD, PhD Department of Orthopaedics Sahlgrenska University Hospital Göteborg, Sweden

Karim M. Khan

Department of Family Practice & School of Human Kinetics

University of British Columbia Vancouver, Canada

Jüri Kartus, MD, PhD Department of Orthopaedics NÄL-Hospital

Trollhättan, Sweden

Sung-Jae Kim, MD, PhD, FACS

Arthroscopy and Joint Research Institute Department of Orthopaedic Surgery Yonsei University College of Medicine Seoul, Korea

Sumant G. Krishnan, MD W.B. Carrell Memorial Clinic Dallas, Texas, USA

Scott Lawrance, PT, ATC

The Shelbourne Clinic at Methodist Hospital

Indianapolis, Indiana, USA Ronny Lorentzon, MD, PhD Professor

Umeå University Sports Medicine Unit Department of Surgical and Perioperative Science Umeå, Sweden

Vicente Martinez-Sanjuan, MD, PhD Profesor of Radiology

Universidad Cardenal Herrera

ERESA-Hospital General Universitario MR and CT Unit

Valencia, Spain

Jenny McConnell, Grad Dip Manip Ther, MBiomedEng

Centre for Health, Exercise and Sports Medicine

School of Physiotherapy

Faculty of Medicine, Dentistry and Health Sciences

University of Melbourne Australia

McConnell and Clements Physiotherapy Sydney, Australia

Peter J. Millett, MD, MSc Harvard Medical School Brigham & Women’s Hospital Boston, MA, USA

Eric Montesinos-Berry, MD Department of Orthopaedics Hospital Arnau de Vilanova Valencia, Spain

Carmen Monserrat Department of Radiology Hospital Arnau de Vilanova Valencia, Spain

Tomas Movin, MD, PhD Department of Orthopaedics Karolinska University Hospital Karolinska Institutet

Stockholm, Sweden

Maurice Y. Nahabedian, MD, FACS Associate Professor of Plastic Surgery Georgetown University Hospital Washington, USA

Eiki Nomura, MD Department Director Orthopaedic Surgery

Kawasaki Municipal Hospital Kawasaki, Japan

Ron Noy, MD

The Shelbourne Clinic at Methodist Hospital

Indianapolis, Indiana, USA

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Fermín Ordoño, MD, PhD Department of Neurophysiology Hospital Arnau de Vilanova Valencia, Spain

Jaime M. Prat-Pastor, MD, PhD Orthopaedic Biomechanics Group Instituto de Biomecánica de Valencia (IBV)

Universidad Politécnica de Valencia Valencia, Spain

Carlos Puig-Abbs, MD Orthopaedic Surgeon Department of Orthopaedics Hospital Universitario Dr Peset Valencia, Spain

Fernando Revert-Ros Patología Molecular Fundación Valenciana de Investigaciones Biomédicas Valencia, Spain

Esther Roselló-Sastre, MD, PhD Pathologist

Department of Pathology Hospital Universitario Dr. Peset Valencia, Spain

Vicente Sanchis-Alfonso, MD, PhD Member of the International

Patellofemoral Study Group and Member of the ACL Study Group

Staff Orthopaedic Surgeon Department of Orthopaedics Hospital Arnau de Vilanova Valencia, Spain

Juan Saus-Mas Patología Molecular Fundación Valenciana de Investigaciones Biomédicas Valencia, Spain

K. Donald Shelbourne, MD

The Shelbourne Clinic at Methodist Hospital

Indianapolis, Indiana, USA J. Richard Steadman, MD

Steadman Hawkins Sports Medicine Foundation

Vail, Colorado, USA

Alfredo Subías-López, MD Department of Orthopaedics Hospital Lluís Alcanyís Játiva, Valencia, Spain Robert A. Teitge, MD

Member of the “International Patellofemoral Study Group”

Department of Orthopaedics Wayne State University School of Medicine

Detroit, Michigan, USA Roger Torga-Spak, MD Instituto Universitario CEMIC Buenos Aires, Argentina Iván Udvarhelyi, MD Uzsoki Hospital

Orthopaedic & Trauma Department Budapest, Hungary

Damien Van Tiggelen, PT

Department of Rehabilitation Sciences and Physical Therapy

Faculty of Medicine University of Gent Gent, Belgium

Department of Traumatology and Rehabilitation

Military Hospital of Base Queen Astrid Brussels, Belgium

Tracy M. Vogrin

Center for Sports Medicine

Department of Orthopaedic Surgery University of Pittsburgh Medical Center

Pittsburgh, PA, USA Suzanne Werner, PT, PhD Associated Professor Dpt Physical Therapy