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McQuivey KS, Braithwaite C, Pollock JR, Moore ML, Brinkman JC, Haglin J, Austin R, Spangehl MJ, Bingham JS. Patellar Resurfacing Is Not a Risk Factor for Postoperative Patella Baja in Total Knee Arthroplasty. Arthroplast Today 2024; 28:101411. [PMID: 38983940 PMCID: PMC11231528 DOI: 10.1016/j.artd.2024.101411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/25/2024] [Accepted: 04/28/2024] [Indexed: 07/11/2024] Open
Abstract
Background Patella baja is a known complication of total knee arthroplasty (TKA). There is a limited understanding of the association between patellar resurfacing and the incidence of patella baja. We aimed to compare rates of patella baja between unresurfaced and resurfaced patellas in patients undergoing TKA. Methods A retrospective review of patients who underwent TKA between October 2009 and January 2020 was performed. Patients were included if they had at least one preoperative radiograph and a 1-year follow-up radiograph. Blackburne-Peel index (BPI) and Insall-Salvati ratios (ISRs) were measured on preoperative and 1-year postoperative radiographs and were used to define patella baja vs pseudopatella baja. Statistical analysis was performed using a linear model analysis of variance and the Fisher's exact test. Results Three hundred eighteen TKAs were included, with 176 being resurfaced and 142 unresurfaced patellas. Of the resurfaced group, 4% (7/176) had true patella baja, compared to 5.6% (8/142) of the unresurfaced patellas. Of the resurfaced patellas, 8% (14/176) had pseudopatella baja, compared to 7% (10/142) in the unresurfaced group. Patellar resurfacing was not associated with a higher incidence of patella baja (P = .60) or pseudopatella baja (P = .83). Lower preoperative ISRs (P = .04) and BPIs (0.03) were highly predictive of a higher incidence of patella baja post-TKA. Conclusions Patellar resurfacing in TKA is not associated with a higher incidence of patella baja in TKA when compared to unresurfaced patellas. Lower preoperative ISRs and BPIs are highly predictive of a higher incidence of postoperative patella baja.
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Affiliation(s)
- Kade S. McQuivey
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Collin Braithwaite
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | | | - M. Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Jack Haglin
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Roman Austin
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Mark J. Spangehl
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S. Bingham
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Sambri A, Paganelli C, Parisi SC, Filippini M, Cevolani L, Stimolo D, Bortoli M, Guarino A, Bruschi A, Fiore M, Campanacci DA, Donati DM, De Paolis M. Does Patellar Height Influence Range of Motion and Anterior Knee Pain after Distal Femur Endoprosthesis Reconstruction? J Clin Med 2024; 13:4194. [PMID: 39064234 PMCID: PMC11277792 DOI: 10.3390/jcm13144194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Objectives: This study aims to evaluate the patellar height changes after distal femur (DF) endoprosthetic replacement (EPR) and its impact on anterior knee pain (AKP) and range of motion (ROM). Methods: A retrospective review of three institutions' databases was performed. The patellar height was determined using the modified Insall-Salvati ratio (MIS), the Blackburne-Peel (BP) and the Caton-Deschamps (CD) indexes. Data regarding AKP and ROM were collected. Results: A total of 199 patients were included. The mean age at presentation was 37.9 ± 23.1 years. The mean one-year follow-up MIS, BP and CD were 1.52 (sd: 0.41), 0.82 (sd: 0.33) and 0.93 (sd: 0.33). Patellar height decreased significantly compared to the pre-operative values according to all three scores (p < 0.001). AKP was reported by 34 (17.1%) patients at 1 year follow-up. Patients with patella baja (MIS < 1.2) or pseudo patella baja (CD < 0.6) had a higher incidence of AKP (p = 0.037 and p = 0.024, respectively). The mean flexion ROM was 91°, with a direct correlation with patellar height (MIS p = 0.020, BP p = 0.036 and CD p = 0.036). Conclusion: The restoration of the native position of the joint line in DF EPR is important to maintain optimal patellofemoral biomechanics. Despite surgeons' tendency toward a reduction in patellar height with respect to pre-operative values, an increase in patellar height might help to achieve better knee flexion and reduce AKP.
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Affiliation(s)
- Andrea Sambri
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Chiara Paganelli
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Stefania Claudia Parisi
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Matteo Filippini
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Luca Cevolani
- Orthopaedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.C.); (D.M.D.)
| | - Davide Stimolo
- Orthopaedic Oncology Unit, Azienda Ospedaliera Universitaria Careggi, 50134 Firenze, Italy; (D.S.); (A.G.); (D.A.C.)
| | - Marta Bortoli
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Andrea Guarino
- Orthopaedic Oncology Unit, Azienda Ospedaliera Universitaria Careggi, 50134 Firenze, Italy; (D.S.); (A.G.); (D.A.C.)
| | - Alessandro Bruschi
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Michele Fiore
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
| | - Domenico Andrea Campanacci
- Orthopaedic Oncology Unit, Azienda Ospedaliera Universitaria Careggi, 50134 Firenze, Italy; (D.S.); (A.G.); (D.A.C.)
| | - Davide Maria Donati
- Orthopaedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.C.); (D.M.D.)
| | - Massimiliano De Paolis
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.P.); (S.C.P.); (M.F.); (M.B.); (A.B.); (M.F.); (M.D.P.)
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Costa TAAO, Bernardes F, Miradouro J, Pereira J, Barreira P, Carvalho J. Modified Z-plasty of the Patellar Ligament with Reinforcement of the Quadriceps Tendon in the Treatment of Patella Baja. Rev Bras Ortop 2024; 59:e123-e126. [PMID: 39027191 PMCID: PMC11254429 DOI: 10.1055/s-0043-1770967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/27/2022] [Indexed: 07/20/2024] Open
Abstract
Patella baja is an infrequent knee pathology, but it is limiting due to joint stiffness and localized pain in the anterior region of the knee. It may occur after trauma, prolonged immobilization or local surgical intervention. The striking pathological finding is the shortening and increase in thickness of the patellar ligament. Several surgical techniques have been described for its treatment, and there is no standardized treatment. We describe the case of a 73-year-old female patient who presented with knee stiffness, significant functional deficit, and patella baja after total knee arthroplasty. She underwent a recently described soft tissue surgical procedure, with excellent functional evolution, improving from a Lysholm Knee Score of 16 to 81 points, allowing early mobilization and return to daily life activities.
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Affiliation(s)
| | | | | | - Joana Pereira
- Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | | | - João Carvalho
- Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
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Liu Z, Wu J, Gao X, Qin Z, Tian R, Wang C. Deep learning-based automatic measurement system for patellar height: a multicenter retrospective study. J Orthop Surg Res 2024; 19:324. [PMID: 38822361 PMCID: PMC11141039 DOI: 10.1186/s13018-024-04809-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/22/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The patellar height index is important; however, the measurement procedures are time-consuming and prone to significant variability among and within observers. We developed a deep learning-based automatic measurement system for the patellar height and evaluated its performance and generalization ability to accurately measure the patellar height index. METHODS We developed a dataset containing 3,923 lateral knee X-ray images. Notably, all X-ray images were from three tertiary level A hospitals, and 2,341 cases were included in the analysis after screening. By manually labeling key points, the model was trained using the residual network (ResNet) and high-resolution network (HRNet) for human pose estimation architectures to measure the patellar height index. Various data enhancement techniques were used to enhance the robustness of the model. The root mean square error (RMSE), object keypoint similarity (OKS), and percentage of correct keypoint (PCK) metrics were used to evaluate the training results. In addition, we used the intraclass correlation coefficient (ICC) to assess the consistency between manual and automatic measurements. RESULTS The HRNet model performed excellently in keypoint detection tasks by comparing different deep learning models. Furthermore, the pose_hrnet_w48 model was particularly outstanding in the RMSE, OKS, and PCK metrics, and the Insall-Salvati index (ISI) automatically calculated by this model was also highly consistent with the manual measurements (intraclass correlation coefficient [ICC], 0.809-0.885). This evidence demonstrates the accuracy and generalizability of this deep learning system in practical applications. CONCLUSION We successfully developed a deep learning-based automatic measurement system for the patellar height. The system demonstrated accuracy comparable to that of experienced radiologists and a strong generalizability across different datasets. It provides an essential tool for assessing and treating knee diseases early and monitoring and rehabilitation after knee surgery. Due to the potential bias in the selection of datasets in this study, different datasets should be examined in the future to optimize the model so that it can be reliably applied in clinical practice. TRIAL REGISTRATION The study was registered at the Medical Research Registration and Filing Information System (medicalresearch.org.cn) MR-61-23-013065. Date of registration: May 04, 2023 (retrospectively registered).
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Affiliation(s)
- Zeyu Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jiangjiang Wu
- College of Information and Communication Engineering, Harbin Engineering University, Heilongjiang, Harbin, China
| | - Xu Gao
- Department of Orthopedics, Xi'an Honghui Hospital, Xi'an, Shaanxi, China
| | - Zhipeng Qin
- Department of Orthopedics, The Second Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Run Tian
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Chunsheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Ragab A, Gwyn R, Davies A. Effect of preservation of Hoffa's fat pad on patellar height in primary total knee arthroplasty procedures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2015-2019. [PMID: 38514577 DOI: 10.1007/s00590-024-03880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND We have previously reported our experience of the effect of complete excision of Hoffa's fat pad on patella height post TKR. In this study, we compared the change of patellar height post TKR before and after the senior author changed his practice to preserving Hoffa's fat pad. METHODS This was a retrospective analysis of a prospective series of TKRs performed or directly supervised by the senior author. In Group 1 were 72 patients performed before April 2011 who had complete excision of Hoffa's fat pad to maximise exposure during the procedure. In Group 2 were 138 patients performed after April 2011 who had the minimum excision of Hoffa's fat pad to allow adequate surgical exposure. The surgical technique and rehabilitation protocol were identical in all other respects. Patellar height was assessed using the Caton-Deschamps Index both immediately postoperative and at a minimum follow up of 1 year. RESULTS Group 1 included 28 males, 44 females with mean age 68.36 years. The mean CDI in this group changed from 0.54 immediately post-operatively to 0.46 at minimum one year follow-up (P = 0.001) indicating progressive patella baja. Group 2 included 56 males, 82 females with mean age 65 years. The mean CDI changed from 0.67 immediately post-operative to 0.68 at minimum one year post follow-up (P = 0.32) indicating no statistically or clinically relevant post-operative change in patellar height. CONCLUSION Total excision of Hoffa's fat pad is associated with progressive post-operative patella baja. This can be avoided by resecting the minimum amount of fat pad to allow adequate exposure during the procedure.
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Affiliation(s)
- Abdelaleem Ragab
- Health Education and Improvement Wales, Tu Dysgu, Cefn Coed, Nantgarw, CF15 7QQ, UK.
- Trauma and Orthopaedics Department, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, NP20 2UB, UK.
| | - Rhodri Gwyn
- Morriston Hospital, Swansea Bay University Health Board, Heol Maes Eglwys, Morriston, Cwmrhydyceirw, Swansea, SA6 6NL, UK
| | - Andrew Davies
- Morriston Hospital, Swansea Bay University Health Board, Heol Maes Eglwys, Morriston, Cwmrhydyceirw, Swansea, SA6 6NL, UK
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Tran Quoc L, Le Khanh T, Mai Thi Hong N, Pham Son T. Influence of Changes in Patella Indices on Total Knee Replacement Surgery Outcomes. Orthop Rev (Pavia) 2024; 16:116365. [PMID: 38682045 PMCID: PMC11045340 DOI: 10.52965/001c.116365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/24/2024] [Indexed: 05/01/2024] Open
Abstract
Summary Total knee replacement is increasingly widely prescribed, not only for degenerative joint disease but also for other problems such as articular cartilage disease, misalignment due to causes other than degeneration, bone and joint cancer, and diseases that cause joint destruction. However, changes in knee joint biomechanics as well as complications of the patellofemoral joint after surgery lead to instability, joint pain, patellar rupture, and patellar tendon rupture. These are issues that challenge surgeons as well as make patients hesitant when considering knee replacement surgery. Understanding the changes in patella index that can occur after total knee replacement surgery will help surgeons carefully evaluate patients before surgery and calculate intraoperative techniques to minimize complications. Methods Fifty-eight patients with 62 knees were diagnosed with osteoarthritis and underwent total knee replacement surgery. All patients had clinical and radiographic evaluation of the knee joint before and after surgery. Results Patellar indexes did not change significantly after surgery compared to before surgery. Before surgery, 2 patients (3.23%) had true patella baja. After surgery, 7 patients (11.29%) had true patella baja and 3 patients (4.84%) had pseudo-patella baja. The average knee flexion amplitude after surgery was 103.11±15.440, with only 2 patients losing extension >50º. The average KS score after surgery was 83.69±9.98, significantly improved compared to before surgery 33.44±11.38. Similarly, KFS score after surgery was 81.01±8.84 compared to before surgery 37.05±8.08. Conclusion Changes in index of the patella before and after surgery affect the surgical results, the normal patella group has better results than the group with patella baja.
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Affiliation(s)
- Lam Tran Quoc
- Ha Noi University Public Health
- Pham Ngoc Thach General Hospital
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Flevas DA, Brenneis M, Nocon A, Gkiatas I, Pirzada W, Tsakotos G, Sculco PK. Incidence of patella baja and pseudopatella baja in aseptic revision total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:1703-1712. [PMID: 38488903 DOI: 10.1007/s00402-024-05234-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION There are two variants regarding the low location of the patella in relation to the tibio-femoral joint line: patella baja (PB) and pseudo-patella baja (PPB). The purpose of this study is to investigate the incidence of PB and PPB in a cohort of patients that underwent revision total knee arthroplasty (rTKA) for aseptic reasons and describe any differences in each group's ROM. METHODS This retrospective study included 114 patients that underwent aseptic revision TKA surgery between 2017 and 2022. Patients were revised either for stiffness (Group 1) or aseptic loosening/instability (Group 2). The Insall-Salvati ratio (ISR) and Blackburne-Peel ratio (BPR) were used to evaluate the patellar position. ISR < 0.8 defined PB, while cases with ISR ≥ 0.8 and BPI < 0.54 were defined as PPB. ROM was measured and a subanalysis was conducted to investigate the progression of the values of ISR and BPR. RESULTS 55 patients comprised Group 1, and 59 patients comprised Group 2. Overall, 13 cases (11.4%) had PB before rTKA and 24 (21%) had PB after rTKA. Cases with PPB were 13 (11.4%) before and 34 (29.9%) after rTKA. Group 1 patients presented with more PB before and after rTKA (12.8% vs 10.2% and 27.3% vs 15.2% respectively). However, after rTKA Group 1 patients presented with less PPB (20%) compared to Group 2 (39%) (p = 0.02). In Group 1, patients with PPB after rTKA had less ROM compared to those without PPB [83.2 (± 21.9) vs 102.1 (± 19.9) (p = 0.025)]. The subanalysis (69 patients) showed a statistically significant decrease in ISR before and after rTKA (p = 0.041), and from the native knee to post-rTKA (p = 0.001). There was a statistically significant decrease in BPR before and after rTKA (p = 0.001) and from the native knee to both pre- and post-rTKA (p < 001). CONCLUSION After undergoing rTKA, the incidences of both patella baja (PB) and pseudo-patella baja (PPB) increased. Stiffness in the knee was associated with a higher incidence of PB, while non-stiffness cases showed a significantly higher incidence of PPB. Patients with stiff knees and PPB after rTKA experienced a significant reduction in range of motion (ROM). Additionally, the study revealed a noteworthy decrease in ISR and BPR with each subsequent surgery. This information is crucial for healthcare providers, as it sheds light on potential risks and outcomes of rTKA, allowing for improved patient management and surgical decision-making. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dimitrios A Flevas
- Hospital for Special Surgery, Stavros Niarchos Foundation Complex Joint Reconstruction Center, 535 East 70th Street, New York, NY, 10021, USA.
| | - Marco Brenneis
- Hospital for Special Surgery, Stavros Niarchos Foundation Complex Joint Reconstruction Center, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt, Main, Germany
| | - Allina Nocon
- Hospital for Special Surgery, Stavros Niarchos Foundation Complex Joint Reconstruction Center, 535 East 70th Street, New York, NY, 10021, USA
| | - Ioannis Gkiatas
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina, Greece
| | - Wali Pirzada
- Hospital for Special Surgery, Stavros Niarchos Foundation Complex Joint Reconstruction Center, 535 East 70th Street, New York, NY, 10021, USA
| | - Georgios Tsakotos
- Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter K Sculco
- Hospital for Special Surgery, Stavros Niarchos Foundation Complex Joint Reconstruction Center, 535 East 70th Street, New York, NY, 10021, USA
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Murase F, Takegami Y, Tokutake K, Oyama H, Arakawa O, Takatsu T, Nakashima H, Mishima K, Imagama S. Fracture of the patella involving inferior pole is associated with postoperative patella baja - A retrospective multicenter study. J Orthop Sci 2024:S0949-2658(24)00053-8. [PMID: 38561304 DOI: 10.1016/j.jos.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The patella fracture involving of inferior pole fractures (IPF) may be associated with patella baja, However, the clinical impact of this condition remains unclear. This study aims to clarify 1) the incidence of patella baja following patellar fracture surgery, 2) the associated clinical outcomes with and without the presence of patella baja, and 3) the potential correlation between the detection of IPF on CT and the occurrence of patella baja. METHODS We conducted a retrospective multicenter study involving 251 patients who underwent surgical treatment for patellar fractures. Patients were divided into the patella baja (PB; n = 49) group and patella norma (PN; n = 202) group. Data collected included demographics, radiographic findings, surgical details, and postoperative complications. We compared these items between PB group and PN group. Logistic regression analyses were used to identify risk factors for patella baja. RESULTS Immediately following surgery, 36 (14.3%) patients presented with patella baja which increased to 49 cases (19.5%) at six months postoperatively. There is no statistically significant difference in the demographics, surgical details, clinical outcomes and complication between PB group and PN group. While, in the radiographical assessment, the prevalence of IPF on CT scan in the patella baja group was significantly higher than that in the patella norma group. By logistic regression analysis, IPFP on CT was identified as an independent risk factor for patella baja. (odds ratio 2.11, 95% confidence interval: 1.03-4.33, p = 0.042). CONCLUSION In patients with patellar fractures, the incidence of patella baja increased from 14.3% immediately post-surgery to 19.5% at the six-month check-up. No significant differences were observed in clinical outcomes between the patella baja group and the norma group. The patella fracture involving IPF on CT emerged as a predictive factor for patella baja.
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Affiliation(s)
- Fuminori Murase
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Oyama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Oki Arakawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tetsuro Takatsu
- Department of Orthopaedic Surgery, Gifu Prefecture Tajimi Hospital, Tajimi, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Mishima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Cheppalli NS, Purudappa PP, Price R, Kolwadkar Y, Metikala S. Isolated lateral-sided knee pain in total knee arthroplasty. A review. Orthop Rev (Pavia) 2024; 16:93014. [PMID: 38505137 PMCID: PMC10950199 DOI: 10.52965/001c.93014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/08/2024] [Indexed: 03/21/2024] Open
Abstract
Isolated lateral-sided knee pain is a unique problem following total knee arthroplasty (TKA). Reported causes include soft tissue impingement against extruded cement, an overhanging tibial tray, remnant osteophytes rubbing against the iliotibial band (ITB), popliteal tendon impingement, fabella syndrome, and synovial tissue impingement in the lateral gutter. In addition, iliotibial band traction syndrome secondary to guided motion Bi-cruciate stabilizing knee arthroplasty has been recognized as a new clinical entity. Initial work up should include ruling out the most common causes of painful TKA including infection, aseptic loosening, and instability. Radiographs and CT scan are utilized to identify potential source of pain. Ultrasound evaluation (with elicited probe tenderness) can increase diagnostic accuracy. Ultrasound guided local anesthetic injections can confirm the source of pain. Anti-inflammatory medications, physical therapy with ITB stretches, and therapeutic local steroid injections are initial treatment modalities. Satisfactory resolution of symptoms may require surgical intervention directed at the specific cause and may avoid the morbidity associated with revision TKA.
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Affiliation(s)
| | | | - Ryan Price
- Orthopedic Surgery University of New Mexico School of Medicine
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10
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D'Ambrosi R, Rubino F, Ursino C, Mariani I, Ursino N, Formica M, Prinz J, Migliorini F. Change in patellar height in medial and lateral unicompartmental knee arthroplasty: a clinical trial. Arch Orthop Trauma Surg 2024; 144:1345-1352. [PMID: 38108862 PMCID: PMC10896931 DOI: 10.1007/s00402-023-05139-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Evidence on patellar height changes following unicompartmental knee arthroplasty (UKA) is lacking. Therefore, this study compared the patella height in patients who underwent medial versus lateral UKA. Moreover, a subgroup analysis was conducted to investigate whether sex, age, and BMI of the patients exert an influence on the postoperative patellar height. METHODS Radiographs and hospital records of patients undergoing UKA were prospectively collected. Surgeries were performed by one author with long experience in UKA in a highly standardised fashion. The implants were fixed-bearing medial PPK (Zimmer Biomet, Warsaw, Indiana, USA) and fixed-bearing lateral ZUK (Lima Corporate, Udine, Italy). The patellar height was measured using the Insall-Salvati and Caton-Deschamps indices. RESULTS A total of 203 patients were included: 119 patients were included in the medial and 84 in the lateral UKA. The mean age of the patients was 68.9 ± 6.7 years, and the mean BMI was 28.1 ± 4.1 kg/m2. 54% (110 of 203 patients) were women. On admission, between-group comparability was found in age, BMI, sex, and length of the follow-up. No between-group and within-group difference was detected pre- and post-operatively in the Insall-Salvati and Caton-Deschamps indices in patients who have undergone medial versus lateral UKA. Concerning the subgroup analyses, no between-group and within-group difference was detected pre- and post-operatively in all comparisons according to sex, age, and BMI. CONCLUSION No difference was found in patella height in patients who have undergone medial compared to lateral UKA. Furthermore, there was no evidence of an association between patient characteristics (sex, age, BMI) and patella height between medial and lateral UKA.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Francesco Rubino
- Orthopaedic Clinic, IRCCS Hospital Policlinico San Martino, Genoa, Italy
- DISC - Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Ursino
- Orthopaedic Clinic, IRCCS Hospital Policlinico San Martino, Genoa, Italy
- DISC - Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Ilaria Mariani
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Matteo Formica
- Orthopaedic Clinic, IRCCS Hospital Policlinico San Martino, Genoa, Italy
- DISC - Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Julia Prinz
- Department of Ophthalmology, RWTH University Hospital, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
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Tischer T, Geier A, Lutter C, Enz A, Bader R, Kebbach M. Patella height influences patellofemoral contact and kinematics following cruciate-retaining total knee replacement. J Orthop Res 2023; 41:793-802. [PMID: 35949157 DOI: 10.1002/jor.25425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 06/02/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023]
Abstract
The role of patella height is discussed controversially in total knee arthroplasty (TKA). Therefore, this computational study aims to systematically analyze the biomechanical effect of different patella heights on patellofemoral (PF) forces and kinematics after cruciate-retaining (CR) TKA. We implemented a CR bicondylar TKA with a dome patellar button in a validated dynamic musculoskeletal multibody model of a male human knee joint. Retropatellar dynamics (contact force [N], shear force [N], patellar shift [mm], tilt [°], and rotation [°]) were evaluated during dual-limb squat motion (flexion from 0° to 90°) with simulated active muscle forces and the effects of different patella heights (Blackburne-Peel [BP] ratio of 0.39, 0.49, 0.65, 0.85, 1.01, and 1.1 were systematically examined). As active knee flexion increased, PF contact force also increased. Patella alta (BP = 1.1) resulted in higher PF contact forces compared to normal patella height (BP = 0.65) by up to 16%. Contrarily, patella baja was associated with decreased PF forces by 7%. Compared to patella baja (BP = 0.39), patella alta (BP = 1.1) considerably increased the contact force by up to 25%. Different patellar heights mainly affected PF shear forces during early knee flexion. Concerning PF kinematics, patella alta (BP = 1.1) yielded a greater lateral tilt of more than 4° and higher patellar rotation by up to 3° during deep knee flexion, compared to normal patella height (BP = 0.65). Our computational study indicates that patella alta is associated with the highest PF contact and shear force after the implantation of a CR bicondylar TKA. This should be considered in PF disorders following TKA.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Andreas Geier
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Christoph Lutter
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Andreas Enz
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Rainer Bader
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Maeruan Kebbach
- Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
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Song SJ, Park CH, Lee JW, Lee HW, Kim KI, Bae DK. Infection and Instability Increasing the Risk of Patella Baja and Pseudo-Patella Baja after Revision Total Knee Arthroplasty. Clin Orthop Surg 2023; 15:71-81. [PMID: 36778990 PMCID: PMC9880515 DOI: 10.4055/cios21154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022] Open
Abstract
Background Patella baja with patellar tendon shortening due to traumatic or ischemic injury is a widely known complication after primary total knee arthroplasty (TKA). Pseudo-patella baja may arise from the elevation of the joint line after excessive distal femoral resection. The maintenance of original patellar height is important in revision TKA because postoperative patella baja and pseudo-patella baja can cause inferior biomechanical and clinical results. We investigated the incidence and risk factors of patella baja and pseudo-patella baja after revision TKA. Methods We retrospectively reviewed data for 180 revision TKAs. Patella baja was defined as a truly low-lying patella with an Insall-Salvati ratio (ISR) of < 0.8 and a Blackburne-Peel ratio (BPR) of < 0.54. Pseudo-patella baja was defined as a relatively low-lying patella compared to the joint line within the normal range of ISR and with a BPR of < 0.54. Clinically, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were evaluated. Risk factors increasing the incidence of patella baja and pseudo-patella baja after revision TKA were evaluated using multiple regression analysis. Results Before revision TKA, 169 knees did not exhibit patella baja or pseudo-patella baja, while 9 knees showed patella baja and 2 knees exhibited pseudo-patella baja. At 2 years after revision TKAs, 25 knees (13.9%) showed patella baja and 23 knees (12.8%) exhibited pseudo-patella baja. Despite no differences in the postoperative WOMAC score between groups with and without patella baja and pseudo-patella baja, the postoperative ROM was significantly smaller in the group with patella baja (113.3°) or pseudo patella baja (110.5°) than in the normal group (122.0°). Infection as the cause of revision TKA increased the risk of patella baja (odds ratio, 10.958; p < 0.001), and instability increased the risk of pseudo-patella baja (odds ratio, 11.480; p < 0.001). Conclusions Infection and instability resulted in increases in the incidence of patella baja and pseudo-patella baja after revision TKA. Information about the risk factors of patella baja and pseudo-patella baja will help TKA surgeons plan the height of the patella after revision TKA and improve clinical outcomes.
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Affiliation(s)
- Sang Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Cheol Hee Park
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Jong Whan Lee
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hyun Woo Lee
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Kand Il Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Dae Kyung Bae
- Department of Orthopaedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
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Treatment of acquired patella baja by proximalization tibial tubercle osteotomy significantly improved knee joint function but overall patient-reported outcome measures remain diminished after two to four years of follow-up. Arch Orthop Trauma Surg 2022; 142:2481-2487. [PMID: 33730219 DOI: 10.1007/s00402-021-03863-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Acquired patella baja is often characterized by painful limitation of knee joint range of motion and anterior knee pain (AKP). Only few studies have evaluated the effectiveness of surgical treatment in terms of patient-reported outcome measures (PROM's) and sports activity. Thus, the goal of this study was to assess PROM's and sports activity after proximalization tibial tubercle osteotomy (P-TTO) in patients with symptomatic patella baja. METHODS Between 2016 and 2018, a case series of 11 patients (male/female 4/7; age 48 ± 12 years) were treated by P-TTO and were retrospectively evaluated after a mean of 33.7 months (range 24-51 months). The Tegner activity score and the Kujala anterior knee pain scale were used in addition to a visual analogue scale (VAS; 0-10) regarding self-reported knee joint function and intensity of AKP. Radiographic assessment included the measure of patellar height using the Caton-Deschamps (CD) and Blackburne-Peel (BP) index. RESULTS Postoperatively both the CD and the BP index increased to normality (p < 0.0001; p = 0.0012). Knee joint flexion improved from 100 ± 32° preoperatively to 123 ± 14° postoperatively (p = 0.0235). AKP decreased from 6.5 ± 2.1 points preoperatively to 3.7 ± 2.1 points postoperatively (p = 0.0061). This was accompanied by a significant increase in self-reported knee joint function from 1.8 ± 1.2 points preoperatively to 6.8 ± 2.3 points postoperatively (p = 0.0001) and an increase of the Tegner activity score from 1.8 ± 1.6 points preoperatively to 3.9 ± 1.5 points postoperatively (p = 0.0074). Although the Kujala score improved significantly by an average of 31.55 points (p = 0.001) overall score results remained reduced at 65.6 ± 17.9 points at final follow-up. CONCLUSION P-TTO yielded significant improvements in terms of AKP, subjective knee joint function and sports activity. However, the overall Kujala score results remained reduced, indicating that surgical correction of patellar height is not sufficient to relieve all patients' complaints. In addition, the incidence of postoperative complications was high.
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Bendable osteochondral allografts for patellar resurfacing: a finite element analysis of congruence. J Biomech 2022; 142:111240. [DOI: 10.1016/j.jbiomech.2022.111240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/24/2022]
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Tang DZ, Liu Q, Pan JK, Chen YM, Zhu WH. Autogenous iliotibial band enhancement combined with tendon lengthening plasty to treat patella baja: A case report. World J Clin Cases 2022; 10:1255-1262. [PMID: 35211558 PMCID: PMC8855193 DOI: 10.12998/wjcc.v10.i4.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patella baja is a severe complication after knee injury or surgery, resulting in pain and impaired movement. This disorder is also a substantial challenge for orthopaedic surgeons. Currently, no consensus exists regarding the gold standard management of patella baja. If not appropriately treated, significant dysfunction of the knee joint will occur.
CASE SUMMARY A 46-year-old man with a left patellar fracture was treated with tension band fixation at a local hospital. He had undergone a second operation at the same hospital because of limited knee flexion 6 mo after surgery. Unfortunately, the patellar tendon was ruptured. The patellar tendon was subsequently repaired using an ipsilateral semitendinosus tendon. Two years later, the patient presented to our department with knee pain and loss of range of motion. Autogenous iliotibial band (ITB) enhancement combined with sagittal tendon lengthening plasty was used to improve the symptoms of the knee joint. The patient was followed up for 2 years. The knee joint function of the patient returned to the normal level.
CONCLUSION We successfully treated patella baja using autogenous ITB enhancement combined with sagittal tendon lengthening plasty.
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Affiliation(s)
- De-Zhou Tang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
| | - Qian Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
| | - Jian-Kang Pan
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
| | - Yue-Ming Chen
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
| | - Wei-Hong Zhu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
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Gamma camera imaging (bone scan) in orthopedics: Foot, ankle, knees, and hip. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Reliability of a Caton-Deschamps-derived patella height index for knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:2001-2005. [PMID: 33471223 PMCID: PMC8338832 DOI: 10.1007/s00264-020-04931-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/29/2020] [Indexed: 12/01/2022]
Abstract
Purpose The original Caton-Deschamps index (oCDI) detects functional patella height. It cannot be used in knees with an implanted endoprosthesis. The “modified Caton-Deschamps index” (mCDI) for knee arthroplasty can miss pseudo-patella-infera (PPI), which is common after TKA. A derivate of the oCDI could be a simple analogue to the index published in 1982 using a modified tibial reference point at the anterior proximal point of the inlay, which can indirectly be located on the lateral knee radiograph. It was the aim of this study to determine the intra- and inter-rater agreement of a derived Caton-Deschamps index (dCDI) for knee arthroplasty. We hypothesized that the derived Caton-Deschamps index (dCDI) is a reliable radiological measure for patella height in knee arthroplasty. Methods Several patella height indices were measured by three independent raters in two passes. The second pass was performed after 6 weeks in random order. Intra- and inter-observer agreements were determined and analyzed using the intraclass correlation coefficient (ICC). For radiographic evaluation, digital lateral radiographs of 150 knees before and after primary TKA were used. Results We found high interrater reliability for all analyzed indices. We found the highest agreements for the ISI preop (ICC = 0.914) and postop (ICC = 0.920), respectively. We also found very good intra-rater reliability for the CDI (ICCpreop = 0.954), dCDI (ICCpostop = 0.945), ISI (ICCpreop = 0.960; ICCpostop=0.940) and BPI (ICCpreop = 0.969; ICCpostop = 0.955). Fourteen cases (9.3%) with insignificant PPI were found. Conclusion The derived Caton-Deschamps index (dCDI) can easily be used in knee arthroplasty and demonstrated high intra- and interrater agreement, which was similar to other commonly used and established patella height indices.
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Konrads C, Rejaibia J, Grosse LC, Springer F, Schreiner AJ, Schmidutz F, Erne F. Patella-height analysis and correlation with clinical outcome after primary total knee arthroplasty. J Orthop 2021; 23:169-174. [PMID: 33542595 DOI: 10.1016/j.jor.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/02/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022] Open
Abstract
Background It is the aim of this study to conceptualize a scheme for patellar-height analysis suitable for knees without and with implanted endoprosthesis. Furthermore, patellar-height and change of patellar-height by total-knee-arthroplasty (TKA) should be studied and correlated with clinical outcomes. We hypothesize that not only True-Patella-Infera (TPI) but also Pseudo-Patella-Infera (PPI) might be correlated with elevated anterior-knee-pain and reduced range-of-motion. Methods Several patellar-height indices were measured by three independent raters in two passes. Indices were analyzed and intra- and interobserver agreements were determined. For radiographic and clinical evaluation of 92 knee arthroplasties, the Insall-Salvati Index (ISI) and the Caton-Deschamps Index (CDI) were used to determine patellar-height and especially the amounts of TPI and PPI. Patellar-height was correlated with clinical outcome parameters: pain, ROM, Oxford Knee Score, Knee Society Score, Kujala Score, SF-36, Tegner and Lysholm. Results All used patellar-height indices demonstrated good intra- and interobserver agreement. Low preoperative ROM was correlated with low postoperative ROM after primary TKA. Postoperatively, 2.2% of the patients had a TPI and 9.8% had a PPI. Patella infera was not correlated with reduced subjective or objective clinical outcome parameters. Conclusions Preoperative ROM is a good predictor of postoperative ROM after primary TKA. Patellar-height analysis can be sufficiently performed using the ISI and the CDI, respectively the derived CDI (dCDI) in cases with implanted endoprosthesis. As an alternative to the CDI/dCDI, the BPI/mBPI can be used. There seems to be a certain threshold of acceptable patellar-height reduction, in which clinical outcome is not deteriorated.
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Affiliation(s)
- Christian Konrads
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Jesin Rejaibia
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Lucia C Grosse
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Fabian Springer
- Department of Radiology, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Anna J Schreiner
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Florian Schmidutz
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany.,Department of Orthopaedics, University of Munich (LMU), Munich, Germany
| | - Felix Erne
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
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