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Combined tion and is calculated from the preoperative plan- deformities are not uncommon and the type of ning 100 mg diclofenac fast delivery. A series of drill holes are placed from lateral osteotomy and location depends on the defor- to medial and connected with a chisel. A detailed description of the types and level ment should be at least 7 cm long and 15 mm of the osteotomies is presented in Chapter 11. The fragment is If the articular cartilage has been lost and pulled distally so the proximal hole is aligned osteoarthritis develops, two alternatives are avail- with the distal drill hole, and then a K-wire is used able: (1) restoration of the normal extra-articular to maintain alignment while the fragment is fixed anatomy and stability and (2) replacement of the with 2 lag screws. Options for articular cartilage The same technique is used to lateralize the replacement are biological or prosthetic. In the medial tubercle to restore the normal tibial past 18 years, 11 patients have undergone 14 fresh tubercle–trochlear (TT-TG) groove distance in patellar and trochlear allografts. The most fre- patients who have had an excessive medial quently performed pre-replacement procedure in transfer. It is not unusual to see in our practice this series was shaving chondroplasty, leaving a patients who had medial transfers in knees with painful patella with exposed subchondral patellar 342 Clinical Cases Commented bone and progressive degenerative changes on the Physical Exam. At an average 10 years follow-up we diffuse warmth, soft tissue swelling, crepita- observed 3 failures and 11 good-to-excellent tion with extension, a negative J-sign, marked results. The results of our study suggest that, in increased medial and lateral mobility of the young patients with isolated secondary patello- left patella compared with the nonoperated femoral arthrosis, fresh osteochondral allografts right, there was considerable apprehension in conjunction with correction of predisposing with pressing the patella medially and a com- factors may offer an alternative to patellectomy plete medial dislocation could be demon- and delay prosthetic joint replacement. A 44-year-old woman was normal with examination revealed hip rotation 65° inter- no complaints in her knees until an automo- nal and 35° external, the foot thigh axis was bile accident in which she was driving her car normal, there was moderate pronation of the that was struck from the side by another car. She slid underneath the seat belt, striking Radiographs.
The next step is taking small- successful transplantation of multiple cylin- sized osteochondral cylinders from the edges of drical osteochondral grafts was reported by the medial or lateral femoral condyles order diclofenac 100 mg without a prescription. The last a defect on the medial femoral condyle associ- step is a mosaic-like implantation of the osteo- ated with an ACL deficient knee. His 37-year-old chondral transplants by press fit technique into male patient had no complaint at 3-year follow- drilled holes of recipient area (Figures 12. Specially designed instrumentation serves the recipient site on the x-rays was reported. Conceptually, During rehabilitation, a full range of motion the technique specifically addressed problems of and non-weight-bearing period for 2 to 3 weeks congruency at the recipient site by the implanta- and partial loading (30–40 kg) for 2 weeks are tion of small-sized grafts sequentially arrayed in advised in accordance with site and extent of the a mosaic-like pattern. Full weight bearing after 4 or 5 weeks and nique design has been the procurement of these normal daily activity from 6 to 8 weeks is small grafts from less weight-bearing surfaces, allowed, but sport activity is not recommended thus reducing the potential of donor site mor- during the first postoperative 4 to 6 months. Open mosaicplasty – anterograde graft insertion – on the patella (b) in a cartilage patellar lesion grade III-IV (a). Treatment of Symptomatic Deep Cartilage Defects of the Patella and Trochlea with and without Patellofemoral Malalignment 219 Figure 12. This composite cartilage layer consists, on an an 80% filling rate correlates with good a clini- average, of 70–80% transplanted hyaline carti- cal outcome. Fibrocartilage results from the natural healing Mathematically, the use of same-sized contact- process of the refreshened bony base of the ing rings results in a theoretical 78. According to experimental data, this But, filling the dead spaces with smaller sizes fibrocartilage fills the space between the trans- can improve the coverage of the defect. The planted grafts and also eliminates the minimal special design of the instrumentation can accommodate a 100% filling rate but, naturally, such transplantation requires more graft har- vesting. Patellar and trochlear mosaicplasties: Kissing lesions are Figure 12. In plasty as an effective, inexpensive, one-step resur- contrast, Hangody et al. This morbidity has been uni- is possible between transplanted and surround- form: patellofemoral complaints with strenuous ing hyaline cartilage, as well as hyaline cartilage physical activity.