Patellaluxation im Kindes- und Jugendalter: Aktuelle Entwicklung bei Diagnostik und Therapie

Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review

BACKGROUND

Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion.

PURPOSE

To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion.

METHODS

A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed.

RESULTS

A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period.

CONCLUSION

For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.

Epidemiology, patterns, and mechanisms of pediatric trauma: a review of 12,508 patients

BACKGROUND

Pediatric traumas are common and remain a unique challenge for trauma surgeons. Demographic data provide a crucial source of information to better understand mechanisms and patterns of injury. The aim of this study was to provide this information to improve treatment strategies of potentially preventable morbidity and mortality in children.

MATERIAL AND METHODS

A retrospective review of every pediatric trauma treated in the emergency department (ED) between 2015 and 2019 was performed. Inclusion criteria were the age between 0 and 14 years and admission to the ED after trauma. Demographic data, time of presentation, mechanism of injury and pattern of injury, treatment, and outcome were analyzed. Different injury patterns were assessed in relation to age group, sex, mechanism of injury and treatment.

RESULTS

A total of 12,508 patients were included in this study. All patients were stratified into five age groups: babies under the age of 1 (8.8%), toddlers between 1 and 3 (16.8%), preschool children between 4 and 6 (19.3%), young school children between 7 and 10 (27.1%), and young adolescents between 11 and 14 (27.9%). The predominant sex in all age groups was male. 47.7% of patients were admitted between 4 and 10 pm; 14.8% of the patients arrived between 10 pm and 8 am. Peak months of admissions were May to July. Overall, 2703 fractures, 2924 lacerations and superficial tissue injury, 5151 bruises, 320 joint dislocations, 1284 distortions, 76 burns, and 50 other injuries were treated. Most common mechanisms for fractures were leisure activities, falls, and sports-related activities. Forearm fractures were the most common fractures (39.5%) followed by humerus fractures (14%) and fractures of the hand (12.5%). A total of 700 patients with fractures (25.9%) needed surgery. 8.8% of all patients were hospitalized for at least one day. 4 patients died in the hospital (0.03%).

CONCLUSION

Despite of higher risk, severe injuries in children are rare. Minor injuries and single fractures are common. Treatment should be managed in specialized centers to ensure an interdisciplinary care and fast recovery. Peak times in the late afternoon and evening and summer months should be taken into consideration of personnel planning.

The Impact of Anatomical Predisposition and Mechanism of Trauma on Dislocation of the Patella: A Retrospective Analysis of 104 Cases

BACKGROUND

The aim of this study was to determine whether traumatic dislocation of the patella is provoked by the presence of predisposing factors and examine the role of the mechanism of injury.

METHODS

Cases diagnosed with dislocation of the patella and covered by the workers' compensation program were identified and classified as traumatic based on insurance regulations. We examined predisposing factors (e.g., frontal axis, torsional deviation, trochlear dysplasia, patella alta) in case groups based on age at dislocation and trauma mechanism. Retrospective cohort study, level of evidence III.

RESULTS

Our sample size comprised 104 cases, consisting of 54 children and 50 adults. The most common mechanism of injury in children and adults was rotational trauma. Only 20% of the children and 21% of the adults exhibited no relevant predisposing factors. Group specifically, falls accounted for the highest number of cases exhibiting none of the defined anatomical predisposing factors. Children are more frequently affected by predisposition-related dislocations than adults.

CONCLUSION

The proportion of predispositions is high. A fall, direct impact, or rotational trauma can be viewed as an adequate mechanism of trauma. For successful treatment, it is paramount to analyze the exact mechanism of the trauma and address any underlying predispositions.

Localization and Likelihood of Chondral and Osteochondral Lesions After Patellar Dislocation in Surgically Treated Children and Adolescents

Background

Patellar dislocation is a common injury in children and adolescents. There is a lack of information about concomitant osteochondral lesions in these patients.

Hypothesis

We hypothesized that the likelihood of chondral or osteochondral lesions would increase with each prior patellar dislocation and that the appearance of lesions in surgically treated children and adolescents would be influenced by age, sex, injury mechanism, and body mass index (BMI).

Study Design

Case-control study; Level of evidence, 3.

Methods

Inclusion criteria were (1) age <18 years, (2) surgical treatment with diagnostic arthroscopy of the knee including description of chondral and osteochondral lesions, and (3) maximum time period between the last patellar dislocation and presentation in our department of 6 weeks and maximum of 4 weeks between presentation and surgery. A total of 153 children (173 knees) with a mean age of 13.0 ± 2.1 years were included. All surgical reports and intraoperative arthroscopic imaging were analyzed retrospectively for the location and severity of lesions. The likelihood of lesions was calculated with multiple stepwise regression models regarding injury mechanism, number of dislocations, sex, age, physeal closure, and BMI.

Results

The regression model to predict femoral lesions was statistically significant (χ²[5] = 26.55; P < .001) and identified male sex, BMI ≥25, traumatic injury mechanism, and physeal closure as independent factors associated with the appearance of femoral lesions. The second regression model predicting the appearance of patellar lesions was also statistically significant (χ²[4] = 26.07; P < .001) and identified the traumatic injury mechanism as a single independent predictor for patellar lesions.

Conclusion

BMI ≥25, male sex, and physeal closure were factors significantly associated with femoral chondral and osteochondral lesions in our cohort. In case of traumatic lateral patellar dislocation (LPD), the likelihood of patellar and femoral chondral and osteochondral lesions is significantly higher than in nontraumatic LPD. Early magnetic resonance imaging and surgical treatment should be considered in obese patients, male patients, and patients with physeal closure and after traumatic LPD.

Outcomes, Return to Sport, and Failures of MPFL Reconstruction Using Autografts in Children and Adolescents with Recurrent Patellofemoral Instability: A Systematic Review

INTRODUCTION

This study systematically reviews and updates the current evidence on the outcomes of medial patellofemoral ligament (MPFL) reconstruction using autografts in children and adolescents with recurrent patellofemoral instability. The outcomes of interest were improvements in patient reported outcomes measures (PROMs), return to sport rates, and the rates of surgical failure.

METHODS

This systematic review was performed according to the 2020 PRISMA guidelines. The following electronic databases were accessed in October 2022: PubMed, Scopus, Web of Science. All the clinical studies which investigated the outcomes of MPFL reconstruction using autografts in children and adolescents with recurrent patellofemoral instability were accessed. Only studies which included patients younger than 18 years were considered. Techniques, case reports, guidelines, comments, editorials, letters, protocols, reviews, and meta-analyses were excluded. Studies which included patients with congenital or acute patellofemoral instability were not eligible, nor were those which focused exclusively on hyperlaxity.

RESULTS

Data from 477 patients (510 procedures) were retrieved. Of the patients, 41% (196 of 477) were women. The mean length of follow-up was 33.7 ± 28.8 months. The mean age of the patients was 14.6 ± 1.6 years. At the last follow-up, all PROMs of interest were statistically improved. The mean time to return to sport was 6.1 ± 1.1 months. Of the patients, 27% reduced their level of activity after surgical stabilization. A total of 87% of patients returned to practice sport. A total of 5% (26 of 477) and 2% (9 of 363) of patients experienced further dislocations and subluxations, respectively, during the follow-up period. Moreover, 4% (16 of 403) of patients underwent a further surgical procedure for patellofemoral instability within the follow-up period.

CONCLUSION

MPFL reconstruction using autografts is effective in children and adolescents with recurrent patellofemoral instability.

Midterm Results After Isolated Medial Patellofemoral Ligament Reconstruction as First-Line Surgical Treatment in Skeletally Immature Patients Irrespective of Patellar Height and Trochlear Dysplasia

BACKGROUND

Medial patellofemoral ligament reconstruction in skeletally immature patients who experience lateral patellar dislocation has been reported to yield good results. Whether bony abnormalities such as patellar height and trochlear dysplasia should be addressed additionally is a topic of discussion.

PURPOSE

To evaluate patient-reported outcomes and redislocation rates after isolated medial patellofemoral ligament reconstruction as first-line surgical treatment for lateral patellar dislocation in skeletally immature patients. Further, to analyze epidemiological, intraoperative, and radiographical factors influencing redislocation and clinical outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Prospectively collected data were retrospectively analyzed for adolescent patients younger than 16 years who underwent medial patellofemoral ligament reconstruction between 2014 and 2018. Inclusion criteria were isolated medial patellofemoral ligament reconstruction with gracilis tendon and availability of accurate pre- and postoperative radiographs with the presence of open physes. The patients were questioned regarding further surgery, redislocation, and clinical outcomes using the Tegner Activity Scale, International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm score, and Kujala score. The influence of diverse epidemiological, intraoperative, and radiographical parameters on the redislocation rates and clinical outcome was analyzed.

RESULTS

A total of 54 medial patellofemoral ligament reconstructions (49 patients) met the inclusion criteria. After 4.3 ± 1.7 years (range, 2.0-7.3 years), 45 reconstructions (83.3%) in 41 patients were available for follow-up. The distribution of trochlear dysplasia was as follows: type A and B, 19 cases (42.2%) each; type C, 6 cases (13.3%); and type D, 1 case (2.2%). Patellar redislocation occurred in 3 patients (6.7%). The mean Tegner, subjective IKDC, Lysholm, and Kujala scores at follow-up were 6.3 ± 1.6 (range, 3-9), 93.6 ± 8.8, 95.9 ± 7.4, and 97.9 ± 7.1, respectively. Patellar height and trochlear dysplasia had no influence on redislocation or clinical scores. The Lysholm score was lower in knees with intraoperative retropatellar chondral lesion grade ≥III versus grade <III (89.0 ± 19.2 vs 96.9 ± 3.6, respectively; P = .023); likewise, the Kujala score was lower in knees that were grade ≥III versus grade <III (90.0 ± 19.7 vs 98.1 ± 2.1, respectively; P = .015).

CONCLUSION

Isolated medial patellofemoral ligament reconstruction as first-line surgical treatment in skeletally immature patients yields excellent midterm results, irrespective of patellar height and trochlear dysplasia. Redislocation still occurs in a certain number of patients, and a higher degree of retropatellar chondral lesion is a predictor for a worse clinical outcome.

[Assessment of patellar dislocations in childhood and adolescence : Accident-related or predisposition-related?]

BACKGROUND

Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear.

AIM

This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality.

MATERIAL AND METHODS

Retrospective cohort study, evidence level III. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18 years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma.

RESULTS

A total of 54 patellar dislocations were identified with a patient age of 14 years (range 9-18 years). A mild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% a high proportion of patella alta and a trochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was >75%. In the fall cohort the rate of children without relevant predisposition was highest.

CONCLUSION

The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not.