Influence of age on clinical outcomes of three-dimensional transfer of the tibial tuberosity for patellar instability with patella alta

A Combined Surgical Approach for Recurrent Patellar Dislocation in Adolescents With Patella Alta and Increased Tibial Tuberosity-Trochlear Groove Distance: Improved Clinical Outcomes but Decreased Posterior Tibial Slopes in Skeletally Immature Patients at Minimum 4-Year Follow-Up

PURPOSE

(1) To report the clinical and radiological outcomes of a surgical technique combining anatomic medial patellofemoral ligament reconstruction and tibia tuberosity transfer in adolescents with patella alta and elevated tibial tuberosity-trochlear groove (TT-TG) distance in the treatment of recurrent patellar dislocation; and (2) to investigate the potential risks of growth arrest or developmental deformities associated with this combined technique.

METHODS

Medical records of patients who underwent the combined surgery from 2015 to 2019 were reviewed. This study included adolescents aged between 14 and 18 years with a Caton-Deschamps index (CDI) > 1.30 and TT-TG distance >20 mm, with a minimum follow-up of 4 years. Radiological examinations including lateral views and full-length posteroanterior standing radiographs were investigated to assess patella height by CDI, posterior tibial slope (PTS) angle, side-to-side difference in bone length, and lower extremity alignment by hip-knee-ankle angle; computed tomography scans and magnetic resonance imaging profiles were investigated to evaluate TT-TG distance and staging of growth plate closure. Other evaluations included preoperative and postoperative physical examination, Kujala score, and Tegner activity score. The patients were stratified into 3 subgroups according to an magnetic resonance imaging-based staging system of the growth plate closure, and each outcome was analyzed. A cohort-specific minimal clinically important difference estimation was performed using standard error of measurement.

RESULTS

The average age at the time of surgery was 16.1 years (range, 14.1-17.8). The average follow-up was 5.6 years (range, 4.0-7.6). No recurrent dislocation occurred, and no clinically significant deformity or axis deviation was encountered. Postoperative patellar height by CDI was 1.00 ± 0.11 (range, 0.81-1.15). No significant differences were found in the preoperative and postoperative hip-knee-ankle angle or side-to-side difference in femur/tibia length among all subgroups. A significantly decreased PTS angle was found in patients with open growth plates, from 10.2° ± 1.7° before surgery to 8.1° ± 1.0° after surgery (P = .015). The Kujala score and Tegner score both significantly improved, from 65.5 ± 13.9 before surgery to 90.4 ± 7.2 after surgery in the Kujala score (P < .001) and from 4.0 ± 1.1 before surgery to 4.7 ± 1.3 after surgery in the Tegner score (P < .001). Of the whole cohort, 63.1%, 100%, 47.1%, and 94.1% of patients achieved the minimal clinically important difference for PTS angle, CDI, Tegner score, and Kujala score, respectively.

CONCLUSIONS

This combined technique is safe and effective in treating recurrent patellar dislocation in skeletally mature adolescents with concurrent patella alta (CDI > 1.30) and TT-TG distance >20 mm, permitting patients to have improved knee function and low complication rates. Nonetheless, patients with open growth plates demonstrated a decrease in PTS, which might predispose the knee to recurvatum and osteoarthritis in the long term.

LEVEL OF EVIDENCE

Level IV, controlled case series.

Normal values of the axial patellotrochlear overlap on MRI: Good correlation with patellotrochlear index in patients with no patellofemoral pathology

BACKGROUND

There are several imaging-based measurements for patellofemoral height, which are obtained from sagittal images. However, these methods can be misleading with sagittal oblique slices and when the patella is tilted and/or chronically subluxated. This study aimed to describe a simple method of measuring patellar height using axial patellotrochlear overlap (APTO) on MRI.

METHODS

A retrospective observational study of 97 knees from 251 patients, excluding those with fractures, massive effusion, or patellofemoral conditions. APTO was measured as follows: (1) patellar length (P) - expressed as the number of axial images showing patellar articular cartilage; (2) trochlear overlap (T) - the number of axial images showing the overlap between patellar articular cartilage and articular cartilage of the lateral trochlea. APTO is the ratio T/P. All measurements were performed independently by six raters on two separate occasions. The raters were two orthopaedic consultants, one knee surgery fellow, two consultant musculoskeletal radiologists, and one radiology fellow. The conventional patellotrochlear index (PTI) was measured as a control for all patients by a senior musculoskeletal radiologist.

RESULTS

The mean APTO value was 36.7% (range 14.2-66.6; standard deviation 11.4). There was a positive correlation with the PTI, Pearson correlation coefficient: 0.76, P < 0.001. Intra-observer reliability was good (intraclass correlation coefficient(ICC): 0.66, 95% confidence interval (CI) 0.54, 0.76, P < 0.001). Inter-observer reliability was fair (ICC: 0.51, 95% CI 0.41, 0.6, P < 0.001).

CONCLUSIONS

APTO was shown to be a reliable measurement of patellar height and correlated with existing PTI for patellar height. Measurement of APTO on MRI could be a reliable alternative for the evaluation of patellar height. However, further studies are required to assess its validity in patients with patellofemoral pathology.

Decreased Effective Patellar Tendon Length following Distalization Tibial Tubercle Osteotomy without Patellar Tendon Tenodesis

Background

Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses.

Purpose

To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis.

Study Design

Case series; Level of evidence, 4.

Methods

Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores.

Results

The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union.

Conclusion

Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.

Double-Tunnel Technique Was Similar to Single-Tunnel Technique in Clinical, Imaging and Functional Outcomes for Medial Patellofemoral Ligament Reconstruction: A Randomized Clinical Trial

PURPOSE

This study aimed to compare the clinical, functional, and imaging outcomes of single-tunnel (ST) and double-tunnel (DT) techniques for medial patellofemoral ligament (MPFL) reconstruction.

METHODS

Ninety-four patients with recurrent patellar instability were randomly divided into 2 groups, receiving either ST or DT MPFL reconstruction. Lateral reticulum release (LRR) and tibial tuberosity (TT) transfer were performed as combined procedures when necessary. Preoperative and postoperative clinical characteristics (symptoms and episodes of redislocation), functional outcomes (Kujala, Lysholm, Tegner, IKDC, and KOOS score), and radiological measurements (congruence angle, patellar tilt angle, lateral patellar angle, and lateral patellar translation) were analyzed.

RESULTS

The analysis included data from 90 patients with 48 patients in the ST group and 42 patients in the DT group. Patients were followed up for a mean period of 37.8 (range: 27-50) months in the ST group and 38.6 (range: 25-53) months in the DT group. Forty-three patients in the ST group and 40 patients in the DT group received combined TT transfer, and all patients underwent LRR. At the latest follow-up, 1 patient in ST group experienced redislocation, while no patient in the DT group sustained clinical failure (P = .347). Imaging measurements decreased significantly to the normal range postoperatively. No significant difference was noted between the postoperative radiological results of the 2 groups. All clinical scores significantly improved postoperatively, and no significant difference was observed between the 2 groups except for the higher Lysholm score (P = .031), KOOS symptoms score (P = .021) and KOOS knee-related quality of life score (P = .043) in the DT group.

CONCLUSION

Both techniques could equally mitigate the patellar lateral translation or redislocation. Our results demonstrate several significant differences in functional outcomes that favored DT MPFL reconstruction but no difference in clinical failure rates and radiological results between ST and DT MPFL reconstruction.

LEVEL OF EVIDENCE

Level I, randomized clinical trial.

Three-dimensional transfer of tibial tuberosity for patellar instability with patella alta preserves patellar position and clinical outcomes: A minimum 3-year follow-up study

BACKGROUND

The three-dimensional (3D) transfer of tibial tuberosity has been reported to improve patellofemoral congruity and showed good clinical outcomes during the short follow-up, however, little is known about whether the patellar position and clinical outcomes are preserved at longer follow-ups and the risk factors for poor clinical outcomes.

HYPOTHESIS

We hypothesized that patellar position and clinical outcomes would be preserved and the predisposing factors were associated with poor clinical outcomes after the 3D transfer of tibial tuberosity.

PATIENTS AND METHODS

Thirty-nine patients, with a mean age of 27.9 (15-52) years, who underwent the 3D transfer of the tibial tuberosity were enrolled. Patellar position was evaluated using the Caton-Deschamps index and patellar tilt. Clinical outcomes were evaluated with Lysholm and Kujala scores pre- and postoperatively. Age, body mass index (BMI), radiographic measurements, and range of motion (ROM) were compared between the poor group (defined as <80 points on Kujala score) and the good group (≥80 points). The mean follow-up period was 54.1 (36-100) months.

RESULTS

Patellar position decreased from 1.32 (1.21-1.53) preoperatively to 0.99 (0.84-1.07) at the final follow-up, according to the Caton-Deschamps index (p < 0.01). The mean patellar tilt decreased from 26.0° (21-40°) to 15.1° (5-28°) (p < 0.01). Kujala and Lysholm scales improved from 59.1 to 54.2 to 90.1 and 91.8 at final follow-up, respectively (p < 0.01). Increased BMI, lower femorotibial angle, limited ROM, and poor preoperative clinical outcomes were the predicting factors for poor postoperative clinical outcomes (p < 0.05).

CONCLUSION

The 3D transfer for patellar instability with patella alta preserved the patellar position and clinical outcomes for at least 3 years. Predisposing factors that may potentially affect postoperative clinical outcomes of the 3D transfer of tibial tuberosity include an increased BMI, valgus knee, limited ROM, and poor preoperative clinical outcomes.

Radiographic and Clinical Outcomes After Tibial Tubercle Osteotomy for the Treatment of Patella Alta: A Systematic Review and Meta-analysis

BACKGROUND

Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue-based stabilization.

PURPOSE

To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations.

RESULTS

Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%).

CONCLUSION

TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.

Patella Alta: When to Correct and Impact on Other Anatomic Risk Factors for Patellofemoral Instability

Patella alta is described as abnormally high-riding patella in relation to the femur, the trochlear groove, or the tibia with decreased bony stability. Patella alta represents an important predisposing factor for patellofemoral instability. Different measurement methods are used to define patella alta. Despite the clinical importance of patella alta, there is only limited consensus on cutoff values, indications for treatment, and ideal correction. In addition, the impact of patella alta on other risk factors for lateral patellar instability is significant. This must be considered when assessing clinical complaints and choosing the best individual treatment. Combined surgical interventions may be necessary.

Tibial Tubercle Osteotomy May Not Provide Additional Benefit in Treating Patellar Dislocation With Increased Tibial Tuberosity-Trochlear Groove Distance: A Systematic Review

PURPOSE

To examine the indications and outcomes of medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tubercle osteotomy (TTO) in treating recurrent or habitual patellar dislocation with an increased tibial tuberosity-trochlear groove (TT-TG) distance.

METHODS

We performed a literature search of the established medical databases Cochrane Central, PubMed-MEDLINE, EMBASE, and Web of Science. The inclusion criteria were as follows: skeletally mature patients with recurrent or habitual patellar dislocation and an increased TT-TG distance, treatment with MPFLR combined with a TTO procedure or isolated MPFLR, and reporting of clinical outcomes and complications. Each study was assessed for quality and the level of evidence. The general characteristics, indications, surgical techniques, TT-TG distance, clinical results, imaging evaluation findings, and complications of each study were recorded.

RESULTS

Nine studies consisting of 288 knees met the inclusion criteria. The average Coleman score was 71.56 (range, 55-83). The threshold for an increased TT-TG distance ranged from 16 to 20 mm in the included studies. Similar good postoperative outcomes were reported in patients with an increased TT-TG distance treated with MPFLR with versus without a TTO procedure. The mean postoperative Lysholm score ranged from 75.0 to 94.7 (I² = 87.6%) in the isolated MPFLR group and from 85.0 to 87.6 (I² = 16.3%) in the TTO-with-MPFLR group. Similar postoperative congruence angles were reported in both groups. The postoperative redislocation rate ranged from 0% to 4.2% in the TTO-with-MPFLR group, and no redislocation was found in the isolated MPFLR group. The postoperative apprehension sign was only reported in isolated MPFLR patients.

CONCLUSIONS

The outcomes of MPFLR with or without TTO to treat recurrent or habitual patellar dislocation with an increased TT-TG distance appeared similar. However, this study was limited by the considerable heterogeneity, variety of techniques, variety of TT-TG distances, and variability in patella alta and trochlear dysplasia among the included studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Surgical Management of Patella Alta in Patellofemoral Instability: A Systematic Review and Meta-analysis

Background

Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition.

Purpose

To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques.

Study Design

Systematic review; Level of evidence, 4.

Methods

This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators.

Results

A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48).

Conclusion

Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.

[Combined operation involving tibial tubercle distalization for recurrent patellar dislocation with patella alta]

Objective

To explore the clinical effects of combined operation involving tibial tubercle distalization for the recurrent patellar dislocation with patella alta.

Methods

Between April 2010 and May 2016, 14 cases of recurrent patellar dislocation with patella alta were treated with combined operation involving tibial tubercle distalization. There were 5 males and 9 females with an average age of 18.5 years (range, 13-26 years). The left knee was involved in 9 cases and the right knee in 5 cases. The patella had dislocated 3.3 times on average (range, 2-5 times). The interval between the first dislocation and admission was 19.7 months on average (range, 4-60 months), and the main symptoms were knee pain and limited knee movement. Preoperative X-ray films, CT, and MRI examinations of knee joint showed that the epiphyseal plate closed in all patients. Of all patients, 3 patients had avulsion fracture of the inner edge of patella, and 2 patients had free body in articular cavity. The tibial tuberosity-trochlear groove (TT-TG) distance, patellar-trochlear-groove distance, Caton-Deschamps index, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) score, Kujala score, and Tegner score were compared pre- and post-operation.

Results

All patients had primary wound healing. All patients were followed up 24-72 months with an average of 34.6 months. X-ray film and CT examination showed that the patellar dislocation was corrected and the osteotomy of the tibial tubercle healed with an average healing time of 3.8 months (range, 3-5 month). At 1 day and 1 year after operation, the TT-TG distance, patellar-trochlear-groove distance, and Caton-Deschamps index showed significant differences when compared with preoperative values ( P<0.05), but there was no significant difference between 1 day and 1 year after operation ( P>0.05). At the 1 year and 2 years after operation, the knee ROM, Lysholm score, IKDC score, Kujala score, and Tegner score showed significant differences when compared with preoperative values ( P<0.05), and there was no significant difference between the 1 year and 2 years after operation ( P>0.05).

Conclusion

Combined operation involving tibial tubercle distalization is a safe and reliable method, which has satisfactory short-term effectiveness for the recurrent patellar dislocation with patella alta.

The clinical and radiological results of individualized surgical treatment depending on pathologic abnormalities in recurrent patellar dislocation: low recurrence rate, but unintended patella baja

PURPOSE

To evaluate the clinical and radiological outcomes and chondral lesion change using individualized surgery for recurrent patellar dislocation.

METHODS

A total of 31 knees with recurrent patellar dislocation underwent surgery depending on individual pathologic abnormalities. Pathologic abnormalities including medial laxity, lateral tightness, increased tibial tuberosity (TT)-to-trochlear groove distance (>20 mm), and patella alta (Caton-Deschamps ratio >1.2) were evaluated in each patient. The abnormalities were corrected through medial patellofemoral ligament reconstruction, TT distalization, TT anteromedialization, and lateral retinacula release. The mean follow-up period was 33 months.

RESULTS

There was one recurrent case (3.2%), requiring additional surgery. The mean Kujala scores were significantly (P = 0.002) improved from 75.8 (SD 12.4) to 84.6 (SD 13.1). Tegner scores were significantly improved from 3.7 (range 1-9) to 5.4 (range 2-9) (P < 0.001), as were and visual analogue scale pain scores from 4.7 (SD 2.5) to 2.6 (SD 2.2) (P = 0.001). Caton-Deschamps ratio was significantly decreased from 1.1 (SD 0.2) to 0.9 (SD 0.1) (P < 0.001), regardless of TT distalization. Chondral lesions of the patella and trochlear groove were improved or maintained in 57.1 and 71.4% of patients, respectively.

CONCLUSION

Individualized surgery in recurrent patellar dislocation was effective and safe with a low recurrence rate. However, the possibility of unintended patella baja, which might be related to post-operative anterior knee pain, should be considered.

LEVEL OF EVIDENCE

IV.

Does Patella Tendon Tenodesis Improve Tibial Tubercle Distalization in Treating Patella Alta? A Computational Study

BACKGROUND

Patellofemoral malalignment associated with patella alta may cause pain and arthritis; because of this, the condition sometimes is treated surgically. Two common procedures are tibial tubercle distalization with or without patellar tendon tenodesis. However, the biomechanical consequences of these interventions for patella alta are not clearly understood.

QUESTIONS/PURPOSES

We evaluated changes in patellofemoral joint contact mechanics after tibial tubercle distalization and tibial tubercle distalization combined with patella tendon tenodesis. Specifically, we asked: (1) Are there biomechanical differences between these two types of procedures? (2) Is there an ideal range to distalize the patella?

METHODS

Subject-specific finite-element models were created for 10 individuals with patella alta (mean Insall-Salvati ratio of 1.34 ± 0.05). Input parameters for the finite-element models included subject-specific joint geometry, quadriceps muscle forces, and weightbearing patellofemoral joint kinematics. Virtual operations were conducted to simulate the two procedures. For distalization, the tibial tubercle and patella were displaced distally 4 mm to 20 mm in 4-mm increments based on the original model. At each level of distalization, the patella tendon was attached back to its original insertion to simulate the additional tenodesis procedure. Cartilage stress, contact area, and contact forces were quantified and compared between procedures and distalization levels.

RESULTS

Distalization and distalization + tenodesis reduced patellofemoral joint stress compared with the baseline of 1.02 ± 0.11 MPa. Distalization led to lower cartilage stress than distalization + tenodesis, and the effect size was relatively large (0.88 ± 0.10 MPa vs 0.92 ± 0.10 MPa; mean difference, 0.04 MPa [95% CI, 0.02 MPa-0.05 MPa], p < 0.01; effect size of 1.64 [Cohen's d], with Insall-Salvati ratio decreased to 0.95). For both procedures, the trend of stress reduction plateaued when the Install-Salvati ratio approached 0.95.

CONCLUSIONS

Cartilage stress appears lower using distalization as opposed to distalization + tenodesis in this finite-element analysis simulation. An Insall-Salvati ratio of 0.95 may be an ideal level for distalization; further distalization does not show additional benefits.

CLINICAL RELEVANCE

This study suggests that distalization may result in less stress than distalization + tenodesis, therefore future clinical research might be preferentially directed toward evaluating isolated distalization procedures.