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Hinckel B, Smith J, Tanaka MJ, Matsushita T, Martinez-Cano JP. Patellofemoral instability part 1 (When to operate and soft tissue procedures): State of the art. J ISAKOS 2024:S2059-7754(24)00100-7. [PMID: 38795864 DOI: 10.1016/j.jisako.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation, and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation and patellar height. Surgery with soft tissue procedures include restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.
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Affiliation(s)
- Betina Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Justin Smith
- Atrium Health Musculoskeletal Institute & Sports Medicine, Rock Hill, SC, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Perkins CA, Egger AC, Busch MT, Murata A, Willimon SC. Medial Patellofemoral Ligament Reconstruction With or Without Tibial Tubercle Osteotomy in Carefully Selected Patients Results in a 5% Revision Rate: A Preliminary Analysis. J Pediatr Orthop 2024; 44:e144-e150. [PMID: 38031489 DOI: 10.1097/bpo.0000000000002582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE The purpose was to assess the outcomes of medial patellofemoral ligament (MPFL) allograft reconstruction with or without tibial tubercle osteotomy (TTO) in adolescents, with a focus on evaluating demographic and imaging characteristics on outcomes. METHODS A single-institution retrospective study was performed of patients ages 12 to 19 years who underwent MPFL reconstruction +/- TTO for the treatment of lateral patellar instability. Demographic, clinical, surgical, and postoperative information was collected. All x-ray and magnetic resonance imaging measurements were completed independently by 2 surgeons. Patients were contacted to complete patient-reported outcomes at a minimum of 2 years following surgery. The primary outcome measure was recurrent instability resulting in revision surgery. RESULTS Seventy-eight knees in 74 patients, with a median age of 15.3 years (interquartile range: 14.4, 16.1), were included. Forty-five knees underwent isolated MPFL reconstruction and 33 knees had a combined MPFL + TTO. The knees that underwent MPFL + TTO had significantly greater tibial tubercle-trochlear groove distance (19.0 mm vs. 15.4 mm, P =0.015) and patellar tendon-lateral trochlear ridge distance (10.9 mm vs. 5.9 mm, P =0.018) than the knees treated with isolated MPFL reconstruction. Four knees (5.1%) underwent revision stabilization surgery, including 3 knees in the MPFL cohort (6.7%) and 1 knee in the MPFL + TTO cohort (3.0%). The rate of failure between the MPFL and MPFL + TTO knees was not significantly different, P =0.634. There were no differences in age, sex, body mass index, number of dislocations, or any imaging characteristics in patients who underwent revision versus those who did not. Patient-reported outcomes were collected on 50 knees at a median of 36 months (interquartile range: 24, 54) after surgery, and no differences were noted between cohorts. CONCLUSIONS Patellar stabilization surgery, including MPFL reconstruction and TTO in carefully selected patients, had excellent revision-free outcomes in 95% of this adolescent cohort. In this case series, those patients whose treatment included TTO had greater tibial tubercle-trochlear groove and patellar tendon-lateral trochlear ridge as compared to the isolated MPFL cohort. Despite previous literature suggesting demographic and imaging characteristics as risks for recurrent instability, we identified no characteristics within these two distinct surgical treatment groups to be predictive of the need for revision stabilization, regardless of the treatment group. LEVEL OF EVIDENCE Level III-retrospective comparison study.
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Affiliation(s)
- Crystal A Perkins
- Department of Pediatric Orthopedics, Children's Healthcare of Atlanta, Atlanta, GA
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Von Heideken J, Iversen MD, Hellsten A, Askenberger M. Adaptation of the Banff Patellofemoral Instability Instrument (BPII) 2.0 into Swedish. Acta Orthop 2023; 94:537-542. [PMID: 37905565 PMCID: PMC10617520 DOI: 10.2340/17453674.2023.21194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/07/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND AND PURPOSE The Banff Patellofemoral Instability Instrument (BPII) 2.0 is a patient-reported outcome measure (PROM) designed specifically for patellofemoral instability. We translated and adapted the BPII 2.0 into Swedish and assessed its psychometric properties. PATIENTS AND METHODS The BPII 2.0 was forward- and back-translated. Children aged 10-16 years with patellar dislocation and instability or recurrent dislocation were recruited. Children completed the Swedish BPII 2.0 and KOOS-Child during their initial visit (t0) and 1 week later (t1). Internal consistency and test-retest reliability were evaluated using intraclass correlation coefficients (ICCs) for the BPII 2.0 and KOOS-Child scores comparison. Pearson correlation coefficients examined concurrent validity of the Swedish BPII 2.0 subscales with KOOS-Child subscales. RESULTS 64 children (46 females), mean age 13.8 (10.0-16.3) years, participated. Time after patellar dislocation or surgery was 3-24 months. 55 patients (86%) returned the second BPII 2.0 and KOOS-Child after an average of 9 (5-22) days. There were no ceiling or floor effects for the total score of the new Swedish BPII 2.0 or for its subscales. BPII 2.0 demonstrated excellent internal consistency at t0 (ICC 0.96, 95% confidence interval [CI] 0.95-0.97) and at t1 (ICC 0.97, CI 0.95-0.98), as well as excellent test-retest reliability (ICC 0.97, CI 0.96-0.98). Concurrent validity of the BPII 2.0 subscales with KOOS-Child subscales was moderate to strong (rho 0.40-0.88). CONCLUSION The Swedish BPII 2.0 showed excellent internal consistency as well as excellent test-retest reliability and is a reliable and valid questionnaire.
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Affiliation(s)
- Johan Von Heideken
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Maura D Iversen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Brigham & Women's Hospital, Division of Rheumatology, Immunology & Immunity, Section of Clinical Sciences, and Department of Medicine, Harvard Medical School, Boston, USA
| | | | - Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Samelis PV, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus 2023; 15:e46743. [PMID: 38021800 PMCID: PMC10631568 DOI: 10.7759/cureus.46743] [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] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
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Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis and Aglaia Kyriakou, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Panagiotis Koulouvaris
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Olga Savvidou
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Andreas Mavrogenis
- Orthopaedics, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Panayiotis J Papagelopoulos
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
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Wang Y, Zhao Y, Huang X, Lei Z, Cao H. Reconstruction of medial patellofemoral ligament with adductor magnus tendon for recurrent patellar dislocation in children: a retrospective comparative cohort study. J Orthop Surg Res 2023; 18:733. [PMID: 37759293 PMCID: PMC10523678 DOI: 10.1186/s13018-023-04221-6] [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: 07/26/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The purpose of current retrospective study was to explore the outcomes of using the adductor magnus tendon to reconstruct the medial patellofemoral ligament in the treatment of recurrent patellar dislocation in children. METHOD Thirty-two children with recurrent patellar dislocation were selected. Sixteen cases in the conservative group, seven males and nine females, with an average age of 11.81 ± 1.28 years; sixteen cases in the surgical group, eight males and eight females, with an average age of 11.56 ± 1.15 years. All patients had no surgery history. The IS index (> 1.2), Q angle (> 20°) and tibial tubercle-femoral trochlear groove (TT-TG) distance (> 20 mm) were measured by X-ray and MRI. The conservative group was treated with closed reduction and a brace, and the surgical group received surgical treatment. Two years after surgery, congruence angle (CA) (- 6° to 6°) and lateral patellofemoral angle (LPFA) (7.7°-18.7°) were measured by X-ray image and all children were evaluated based on Kujala and Lysholm scores. The re-dislocation rate was recorded. Analysis was performed by t test and chi-square with the statistical SPSS software. P < 0.05 was considered a statistically significant difference. Furthermore, we measured the length (mm) of the adductor tendon and MPFL in three knee cadaveric specimens, and also observed the positional relationship between the two structures. RESULT There were no significant differences in sex, age, injury site between groups (P > 0.05). Patients in the two groups were followed up for 2 years in average. Among the 16 cases in the conservative group, 7 cases (43.75%) had recurrence of patellar dislocation, while none of recurrence in the surgical group (P < 0.05). The Lysholm score of the surgical group (94.63 ± 8.99) was significantly better than that of the conservative group (79.31 ± 18.90), and the Kujala score of the surgery group (95.25 ± 10.32) was also significantly better than that of the conservative group (77.06° ± 14.34°) (P < 0.05). The CA and LPFA of the two groups of patients after treatment were significantly recovered. The CA (- 5.81° ± 7.90°) in the surgical group was significantly better than that in the conservative group (20.94° ± 8.21°), and the LPFA (6.44° ± 3.22°) was also significantly better than that in the conservative group (- 9.18 ± 11.08), and the difference is statistically significant (P < 0.05). We found it through autopsy that adductor magnus tendon was 124.33 ± 1.53 mm long, MPFL was 48.67 ± 2.08 mm, and the femoral insertion of the adductor magnus tendon was adjacent to the MPFL femoral insertion. CONCLUSION Reconstruction of Medial patellofemoral ligament with the adductor magnus tendon, fixing with PEEK suture anchors on the patellar side, can achieve satisfactory results in the treatment of children with recurrent patellar dislocation. Compared with conservative treatment, the rate of recurrence is lower and the stability of the patella is better.
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Affiliation(s)
- Yuqi Wang
- Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, People's Republic of China
| | - Yi Zhao
- Department of Plastic and Burn, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, People's Republic of China
| | - Xincheng Huang
- Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, People's Republic of China
| | - Zhuolin Lei
- Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, People's Republic of China
| | - Hong Cao
- Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, People's Republic of China.
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Yamashita S, Ishizuka S, Sakai T, Oba H, Sakaguchi T, Mizuno T, Kawashima I, Tsukahara T, Takahashi S, Kurokouchi K, Imagama S. Potential of patellar height measurement methods in predicting recurrent patellar dislocation incidence: a case-control study. BMC Musculoskelet Disord 2023; 24:707. [PMID: 37670298 PMCID: PMC10478238 DOI: 10.1186/s12891-023-06813-z] [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: 01/10/2023] [Accepted: 08/19/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Recurrent patellar dislocation (RPD) is a multifactorial disease that affects young and active people. Patellar height measurements are used clinically to screen and diagnose knee conditions. However, there are no known studies that have assessed and compared the performance of patellar height indices for predicting the incidence of RPD, which could be used to recommend surgical treatment after primary patellar dislocation. This case-control study aimed to determine if the patellar height index could be used to predict the incidence of RPD, and to identify the optimal method in terms of its diagnostic ability for RPD. METHOD Altogether, 133 patients (52 patients with RPD [Group R] and 81 sex- and age-matched controls [Group C]) were enrolled in this study. The Insall-Salvati (IS), Blackburne-Peel (BP), Caton-Deschamps (CD), and modified IS (mIS) methods were used to measure the patellar height index. The intra-observer and inter-observer reliabilities of these four methods were determined using intraclass correlation coefficients. A receiver operating characteristic curve analysis was performed to evaluate the predictive ability of each index and identify the cut-off values that indicated significantly increased risk of RPD. RESULTS Patient demographics were similar between the two groups. The inter-observer and intra-observer reliabilities were good for all four methods. In patients with RPD, the mean index values for the four methods were significantly higher than those in the matched controls. The area under the curve (AUC) values for IS, BP, CD, and mIS were 0.91 (standard error [SE], 0.03; 95% confidence interval [CI], 0.84-0.96), 0.72 (SE, 0.05; 95% CI, 0.63-0.81), 0.86 (SE, 0.03; 95% CI, 0.79-0.92), and 0.96 (SE, 0.01; 95% CI, 0.94-0.99), respectively. CONCLUSION Patellar height indices had high predictive performance for the incidence of RPD. The mIS method had the highest AUC.
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Affiliation(s)
- Satoshi Yamashita
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
| | - Shinya Ishizuka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan.
| | - Tadahiro Sakai
- Department of Orthopedic Surgery, Toyota Memorial Hospital, Aichi, Japan
| | - Hiroki Oba
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
| | - Takefumi Sakaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
| | - Takafumi Mizuno
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
| | - Itaru Kawashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
| | | | - Shigeo Takahashi
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Kazutoshi Kurokouchi
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Showaku, Nagoya, 4668550, Aichi, Japan
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Papp K, Speth BM, Camathias C. Clinical Insights into the Treatment of Patellofemoral Instability with Medial Patellofemoral Ligament Reconstruction: Pearls and Pitfalls-Lessons Learned from 20 Years. J Pers Med 2023; 13:1240. [PMID: 37623490 PMCID: PMC10455723 DOI: 10.3390/jpm13081240] [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: 03/21/2023] [Revised: 04/25/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
Patellofemoral instability is a prevalent cause of pain and disability in young individuals engaged in athletic activities. Adolescents face a particularly notable risk of patellar dislocation, which can be attributed to rapid skeletal growth, changes in q-angle, ligamentous laxity, higher activity levels, and increased exposure to risk. Specific sports activities carry an elevated risk of patellar dislocation. Younger age and trochlear dysplasia present the highest risk factors for recurrent patellar dislocations. International guidelines recommend conservative therapy following a single patellar dislocation without osteochondral lesions but suggest surgical intervention in recurrent cases. In this study, we have compiled current scientific data on therapy recommendations, focusing on MPFL (medial patellofemoral ligament) reconstruction. We discuss patient selection, surgical indications, graft selection, location and choice of fixation, graft tensioning, and postoperative care.
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Affiliation(s)
- Kata Papp
- Department of Traumatology and Orthopaedic Surgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland
| | - Bernhard M. Speth
- Department of Traumatology and Orthopaedic Surgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland
- Department of Orthopaedic Surgery, University Children’s Hospital Basel, CH-4031 Basel, Switzerland
| | - Carlo Camathias
- Orthopädie für Kinder & Jugendliche, Praxis Zeppelin, CH-9016 St. Gallen, Switzerland
- Faculty of Medicine, University of Basel, CH-4031 Basel, Switzerland
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Lee DY, Kang DG, Jo HS, Heo SJ, Bae JH, Hwang SC. A systematic review and meta-analysis comparing conservative and surgical treatments for acute patellar dislocation in children and adolescents. Knee Surg Relat Res 2023; 35:18. [PMID: 37349852 DOI: 10.1186/s43019-023-00189-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/02/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE This study sought to clarify treatment evidence to treat patellar dislocation by evaluating which treatment could yield better improvement of clinical outcomes for acute patellar dislocation in children and adolescents 18 years of age or younger. MATERIALS AND METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials electronic databases were searched for relevant articles comparing clinical outcomes of conservative and surgical treatments for acute patellar dislocation in children and adolescents published from March 2008 to August 2022. Data searching, extraction, analysis, and quality assessment were performed on the basis of the Cochrane Collaboration guidelines. The quality assessment of each study was investigated using the Physiotherapy Evidence Database (PEDro) critical appraisal scoring system and Newcastle-Ottawa Quality Assessment Scale scores. To calculate the overall combined effect size for each outcome, Review Manager Version 5.3 (The Cochrane Collaboration, Software Update, Oxford) was employed. RESULTS Three randomized controlled trials (RCTs) and one prospective study were investigated. In terms of pain [mean difference (MD) 6.59, 95% confidence interval (CI) 1.73-11.45, I2 0%], there were significantly better outcomes in conservative group. Nevertheless, there were no significant differences in any evaluated outcomes such as redislocation [risk ratio (RR) 1.36, 95% CI 0.72-2.54, I2 65%], Kujala score (MD 3.92, 95% CI -0.17 to 8.01, I2 0%), Tegner score (MD 1.04, 95% CI -0.04 to 2.11, I2 71%), or subjective results (RR 0.99, 95% CI 0.74-1.34, I2 33%) between conservative and surgical treatment groups. CONCLUSIONS Despite better pain outcomes with conservative group, the present study revealed no significant differences in clinical outcomes between conservative treatment and surgical treatment in children and adolescents with acute patellar dislocation. Since there are no significant differences in clinical outcomes between the two groups, routine surgical treatment is not advocated for treating acute patellar dislocation in children and adolescents.
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Affiliation(s)
- Dong-Yeong Lee
- Department of Orthopaedic Surgery, Barun Hospital, Jinju, Republic of Korea
| | - Dong-Geun Kang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Changwon Hospital, Changwon, Republic of Korea
| | - Ho-Seung Jo
- Department of Orthopaedic Surgery, SMG Yeonse Hospital, Changwon, Republic of Korea
| | - Se-Joon Heo
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Ji-Ho Bae
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Sun-Chul Hwang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea.
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Sinikumpu J, Nicolaou N. Current concepts in the treatment of first-time patella dislocation in children and adolescents. J Child Orthop 2023; 17:28-33. [PMID: 36755554 PMCID: PMC9900011 DOI: 10.1177/18632521221149060] [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: 11/20/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023] Open
Abstract
Background Lateral dislocation of the patella is a common injury in children. It can occur in previously healthy and anatomically normal knees, but there are several abnormalities that predispose to patellar instability. Magnetic resonance imaging is an essential part of assessing for associated injuries and risk of further instability. Treatment aims to prevent redislocation, residual instability, osteoarthritis, and allow return to previous activities. The purpose of this review was to assess evidence for management of first-time patella dislocation in children and adolescents. Methods Literature review was performed, accompanied by the current best practice by the authors. Results Non-operative treatment is preferred, except where there are associated injuries such as osteochondral fractures that would benefit from surgery. The exact method of ideal non-operative management is not clearly defined but should focus on restoration of range of movement and strength with bracing as indicated. There seems to be a trend toward operative intervention that may well be inappropriate. Conclusion Further prospective studies are required with focus on the younger patient to fully understand if there is an at-risk group that would benefit from early surgery. Level of evidence level III.
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Affiliation(s)
- Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopaedics, Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Nicolas Nicolaou
- Department of Paediatric Orthopaedic Surgery, Sheffield Children’s Hospital, Sheffield, UK
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A 20-Year Retrospective Study of Children and Adolescents Treated by the Three-in-One Procedure for Patellar Realignment. J Clin Med 2023; 12:jcm12020702. [PMID: 36675630 PMCID: PMC9861102 DOI: 10.3390/jcm12020702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Patellar instability is the most common disorder of the knee during childhood and adolescence. Surgical treatment significantly reduces the rate of redislocation, but the underlying pathologies and pattern of instability may affect the results. We aimed to report the clinical and functional outcomes of the three-in-one procedure for patellar realignment in a cohort of skeletally immature patients with or without syndromes and various patterns of chronic patellar instability. METHODS We retrospectively investigated 126 skeletally immature patients (168 knees) affected by idiopathic or syndromic patellar instability, who underwent patella realignment through a three-in-one procedure. We classified the instability according to the score proposed by Parikh and Lykissas. RESULTS Patellar dislocation was idiopathic in 71 patients (94 knees; 56.0%) and syndromic in 55 (74 knees; 44.0%). The mean age at surgery was 11.5 years (range 4-18) and was significantly lower in syndromic patients. Syndromic patients also exhibited more severe clinical pattern at presentation, based on the Parikh and Lykissas score. The mean follow-up was 5.3 years (range 1.0-15.4). Redislocation occurred in 19 cases, with 10 cases requiring further realignment. The Parikh and Lykissas score and the presence of congenital ligamentous laxity were independent predictors of failure. A total of 22 knees in 18 patients required additional surgical procedures. The post-operative Kujala score was significantly lower in patients with syndromic patellar instability. CONCLUSIONS The type of instability and the presence of underlying syndromes negatively affect the rate of redislocation and the clinical and functional outcome following patellar realignment through the three-in-one procedure. We recommend the consideration of alternative surgical strategies, especially in children with severe syndromic patellar dislocation.
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Jungesblut W, Rupprecht M, Schroeder M, Krajewski KL, Stuecker R, Berger-Groch J, Strahl A, Hubert J, Jungesblut OD. Localization and Likelihood of Chondral and Osteochondral Lesions After Patellar Dislocation in Surgically Treated Children and Adolescents. Orthop J Sports Med 2022; 10:23259671221134102. [PMID: 36504671 PMCID: PMC9732795 DOI: 10.1177/23259671221134102] [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: 07/06/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Wibke Jungesblut
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital,
Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Rupprecht
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital,
Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Schroeder
- Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kara Leigh Krajewski
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital,
Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Stuecker
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital,
Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josephine Berger-Groch
- Department of Trauma, Hand and Reconstructive Surgery, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Strahl
- Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hubert
- Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver D. Jungesblut
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital,
Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, Division of
Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Oliver D. Jungesblut, MD, Department of Pediatric Orthopedics,
Children’s Hospital Hamburg-Altona, Bleickenallee 38, 22763 Hamburg, Germany
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12
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Sasaki E, Kimura Y, Sasaki S, Yamamoto Y, Tsuda E, Ishibashi Y. Clinical outcomes of medial patellofemoral ligament reconstruction using FiberTape and knotless SwiveLock anchors. Knee 2022; 37:71-79. [PMID: 35696836 DOI: 10.1016/j.knee.2022.05.011] [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: 12/29/2020] [Revised: 04/05/2022] [Accepted: 05/27/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND We aimed to prospectively investigate the clinical outcomes of medial patellofemoral ligament (MPFL) reconstruction using polyester high-strength suture tape with knotless anchors. METHOD Forty-three patients (65 knees) were followed for at least 1 year postoperatively, with 27 patients (43 knees) followed for 2 years postoperatively. All patients underwent MPFL reconstruction using polyester high-strength suture tape (FiberTape®; Arthrex) with knotless anchors (SwiveLock®; Arthrex). Repeated dislocation and residual patellar apprehension signs were recorded, and congruence and tilting angles were measured. Changes in Knee Injury and Osteoarthritis Outcome Scale (KOOS) scores and their associations with the preoperative tibial tubercle-trochlear groove (TT-TG) distance were analyzed. RESULTS No repeat dislocations (0%) were observed. One (2.4%) residual positive patellar apprehension sign was noted. The mean tilting angle decreased from 24.8° to 10.7° (P < 0.001), and the mean congruence angle decreased from 24.9° to 4.3° (P < 0.001). At 2 years follow up, all KOOS subscales had improved: pain (92.0 ± 12.9), symptoms (90.2 ± 11.9), activities of daily living (95.7 ± 7.3), sports activity (85.7 ± 16.9), quality of life (87.7 ± 12.9), and patellofemoral (89.0 ± 9.6) outcomes. KOOS subscale scores improved regardless of the preoperative TT-TG distance (21.1 ± 3.5 mm; range, 13.8-29.9 mm). CONCLUSIONS MPFL reconstruction using FiberTape and knotless SwiveLock anchors was performed without sacrificing autologous tissue. No recurrent patellar dislocation was observed during the 2-year follow up period. All KOOS subscale scores improved using FiberTape and SwiveLock anchors in MPFL reconstruction.
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Affiliation(s)
- Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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13
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Schlumberger M, Schuster P, Hofmann S, Mayer P, Immendörfer M, Mayr R, Richter J. Midterm Results After Isolated Medial Patellofemoral Ligament Reconstruction as First-Line Surgical Treatment in Skeletally Immature Patients Irrespective of Patellar Height and Trochlear Dysplasia. Am J Sports Med 2021; 49:3859-3866. [PMID: 34694139 DOI: 10.1177/03635465211050419] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Michael Schlumberger
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Schuster
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany.,Paracelsus Medical Private University, Clinic Nuremberg, Department of Orthopedics and Traumatology, Nuremberg, Germany
| | - Sophie Hofmann
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Mayer
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Micha Immendörfer
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Raul Mayr
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jörg Richter
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
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14
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Abstract
Patellar instability is one of the most prevalent knee disorders, with dislocations occurring in 5 to 43 cases per 10,000 annually. Traumatic patellar dislocation can result in significant morbidity and is associated with patellofemoral chondral injuries and fractures, medial soft tissue disruption, pain, and reduced function, and can lead to patellofemoral osteoarthritis. Chronic and recurrent instability can lead to deformation and incompetence of the medial soft tissue stabilizers. Despite recent gains in understanding the pathoanatomy of this disorder, the management of patients with this condition is complex and remains enigmatic.
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15
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Li LT, Bokshan SL, Lemme NJ, Testa EJ, Owens BD, Cruz AI. Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population. Arthrosc Sports Med Rehabil 2021; 3:e1279-e1286. [PMID: 34712964 PMCID: PMC8527270 DOI: 10.1016/j.asmr.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/31/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. Methods The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. Results There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). Conclusions Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Lambert T. Li
- Address correspondence to Lambert T. Li, B.A., Department of Orthopaedic Surgery, Sports Injury Laboratory, Brown University, Warren Alpert School of Medicine, 1 Kettle Point Ave., Providence, RI 02906, U.S.A.
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16
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Zhao X, Zhang H. Biomechanical Comparison of 2 Patellar Fixation Techniques in Medial Patellofemoral Ligament Reconstruction: Transosseous Sutures vs Suture Anchors. Orthop J Sports Med 2021; 9:23259671211041404. [PMID: 34692878 PMCID: PMC8529315 DOI: 10.1177/23259671211041404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Multiple techniques for fixing a graft to the patella in medial patellofemoral ligament (MPFL) reconstruction have been described; however, no single technique has been shown to be superior to another. Purpose/Hypothesis The purpose of this study was to compare the biomechanical performance of 2 different patellar fixation techniques: suture anchor (SA) and transosseous suture (TS) fixation. The hypothesis was that there would be no significant differences between the groups in ultimate failure load, stiffness, or elongation. Study Design Controlled laboratory study. Methods In this study, a new TS technique was biomechanically compared with the SA technique for MPFL reconstruction using 24 fresh-frozen mature porcine patellae and porcine flexor profundus tendons. The specimens were randomized into 2 groups undergoing MPFL reconstruction using either the SA technique or the TS technique (n = 12 per group). Fixation with TS was completed using 3 No. 2 UltraBraid sutures and three 2-mm transosseous tunnels. SA reconstruction was completed using 2 parallel 3.5-mm titanium SAs with 2 No. 2 UltraBraid sutures. We preconditioned each graft using a force between 5 and 20 N before cyclic loading. Then, the specimens were biomechanically tested (1000 cycles; 5-100 N; 1 Hz) and loaded under tension at 200 mm/min until failure. The ultimate failure load, stiffness, elongation, and failure mode were recorded for each specimen. The Shapiro-Wilk test and independent t tests were used to assess the data. Results The TS technique resulted in a significantly higher mean failure load than did the SA technique (496.18 ± 93.15 vs 399.43 ± 105.35 N; P = .03). The TS technique resulted in less stiffness than did the SA technique (55.42 ± 7.92 vs 72.11 ± 10.64 N/mm; P < .01). There was no significant difference between the groups in elongation. None of the graft fixation/patellar complexes failed during cyclic testing in either group. During the load-to-failure test, the most common mode of failure in the SA group was an anchor being pulled out of the bone, whereas that in the TS group was rupture of the suture material. Conclusion MPFL reconstruction with 3 TSs provided a higher load to failure than did the commonly used fixation method involving SAs.
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Affiliation(s)
- Xin Zhao
- First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hangzhou Zhang
- Department of Orthopedics; Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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17
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Stinson ZS, Davelaar CMF, Kiebzak GM, Edmonds EW. Treatment Decisions in Pediatric Sports Medicine: Do Personal and Professional Bias Affect Decision-Making? Orthop J Sports Med 2021; 9:23259671211046258. [PMID: 34676272 PMCID: PMC8524719 DOI: 10.1177/23259671211046258] [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: 04/16/2021] [Accepted: 06/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Personal and professional biases can affect decision-making regarding
important issues in pediatric sports medicine. Gaining insight into the
opinions of health care professionals who specialize in pediatric sports
medicine will provide information that may be useful for directing ongoing
research in this field. Hypothesis: It was hypothesized that surgeons would demonstrate bias toward early
surgical intervention versus nonsurgeons. In addition, it was hypothesized
that youth sports medicine professionals who were parents of a child with a
previous major sports injury or concussion would be less likely to allow
their child to play American tackle football or return to football after a
concussion. Study Design: Cross-sectional study. Methods: An online survey was provided to the active members of the Pediatric Research
in Sports Medicine Society. We used both professional background information
and responses to questions related to personal experiences with youth sports
injuries to determine potential factors associated with underlying biases.
Survey responses among subgroups were compared using the Fisher exact test.
The Pearson correlation coefficient was used to evaluate years in practice
versus opioid use. Results: Of the survey participants, 62.5% were pediatric surgeons, and 37.5%
represented different nonsurgical youth sports medicine professions.
Surgeons were less likely than nonsurgeons to agree to allow their child to
return to football after sustaining a concussion and completing a concussion
protocol (48% vs 76%, P = .013). Surgeons were more likely
than nonsurgeons to agree to both elective shoulder stabilization after a
first-time dislocation and elective drilling of a stable knee
osteochondritis dissecans (OCD) before nonoperative treatment (41% vs 10%,
P = .003 and 52% vs 23%, P = .013,
respectively). Those who reported having a child with a concussion history
were more likely to support him or her returning to football after a
concussion (65% vs 33%, P = .026). Conclusion: Surgeons were more likely to favor elective shoulder-stabilization surgery
after a first-time dislocation and drilling of a stable knee OCD instead of
nonoperative management. Personal experience of having a child who sustained
a major sports injury or concussion did not demonstrate a bias against
participation in football or return to football after a concussion.
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18
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Changes in patellar morphology following surgical correction of recurrent patellar dislocation in children. J Orthop Surg Res 2021; 16:607. [PMID: 34656140 PMCID: PMC8520291 DOI: 10.1186/s13018-021-02779-7] [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: 08/18/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to evaluate patellar morphological changes following surgical correction of recurrent patellar dislocation in children. Methods A total of 35 immature children aged 5 to 10 years who suffered from bilateral recurrent patellar dislocation associated with abnormal patella morphology were enrolled in this study. The knees with the most frequent dislocations (treated with medial patellar retinacular plasty) were selected as the study group (SG), and those undergoing conservative treatment for the contralateral knee were selected as the control group (CG). Computed tomography (CT) scans were performed on all children preoperatively and at the last follow-up to evaluate morphological characteristics of the patella. Results All the radiological parameters of the patella showed no significant difference between the two groups preoperatively. At the last follow-up for CT scans, no significant differences were found for the relative patellar width (SG, 54.61%; CG, 52.87%; P = 0.086) and the relative patellar thickness (SG, 26.07%; CG, 25.02%; P = 0.243). The radiological parameters including Wiberg angle (SG, 136.25°; CG, 122.65°; P < 0.001), modified Wiberg index (SG, 1.23; CG, 2.65; P < 0.001), and lateral patellar facet angle (SG, 23.35°; CG, 15.26°; P < 0.001) showed statistical differences between the two groups. Conclusions The patellar morphology can be improved by early surgical correction in children with recurrent patellar dislocation. Therefore, early intervention is of great importance for children diagnosed with recurrent patellar dislocation.
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A Prospective Cohort Study on Quality of Life among the Pediatric Population after Surgery for Recurrent Patellar Dislocation. CHILDREN-BASEL 2021; 8:children8100830. [PMID: 34682094 PMCID: PMC8535121 DOI: 10.3390/children8100830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022]
Abstract
Patellofemoral instability is a frequent cause of knee pathology affecting quality of life among the pediatric population. Here, we present a prospective cohort study which included patients who had undergone surgical management using the lateral release and medial imbrication approach (LRMI) or medial patellofemoral ligament reconstruction (MPFL-R). The object of this study was to assess the quality of life among children that have undergone surgical treatment for patellar dislocation. Quality of life was assessed before and after surgery using the Pediatric International Knee Documentation Committee form (Pedi-IKDC), a questionnaire that aims to quantify knee functionality. Postoperative scarring was evaluated using The Stony Brook Scar Evaluation Scale. One hundred and eight patients were selected and grouped according to the type of procedure. Before surgery, the two groups had similar mean Pedi-IKDC scores (41,4 MPFL-R vs. 39,4 LRMI p = 0.314). Improvements were observed in the postoperative scores. The MPFL-R technique showed promising outcomes. When comparing the two surgical groups, there was a significant difference in favor of MPFL-R group (MPFL-R 77.71 points vs. LRMI 59.74 points, p < 0.0001-95% CI (11.22-24.72)). Using the Stony Brook Scar Evaluation Scale, a significant difference in scar quality in favor of MPFL-R was observed (4,5 MPFL-R vs. 2,77 LRMI p = 0.002). In conclusion, this study provides objective evidence-based outcome assessments that support the medial patellofemoral ligament reconstruction technique as the gold standard for patellofemoral instability.
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20
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Assessment of knee flexor muscles strength in patients with patellar instability and its clinical implications for the non-surgical treatment of patients after first patellar dislocation - pilot study. BMC Musculoskelet Disord 2021; 22:740. [PMID: 34454460 PMCID: PMC8403423 DOI: 10.1186/s12891-021-04636-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background Biomechanical studies indicate that during outward rotation of the tibia and the valgus knee joint position, the patella is shifted in the lateral direction. After first-time patellar dislocation, the dynamic position of the femur in relation to the tibia plays an important role in joint stability, because the medial stabilizer of the patella (mostly the MPFL) is damaged or inefficient. The most important factor in controlling the rotational movement of the tibia in relation to the thigh are the hamstring muscles. The aim of the study therefore is to determine whether patients with patellar instability have a significant weakness in the knee flexor muscles, which can predispose to recurrent dislocations. This is an important consideration when planning the rehabilitation of patients with first-time patellar dislocation. Methods The study enrolled 33 patients with confirmed recurrent patellar dislocation, including six patients with bilateral involvement. In the study group, the hamstring muscles (both sides) were evaluated at velocities of 60 and 180 deg/s for the following parameters: peak torque, torque at 30 degrees of knee flexion, angle of peak torque and peak torque hamstring to quadriceps ratio (H/Q ratio). Results In the recurrent patellar dislocation group, a statistically significant weakness in knee flexors was observed for both angular velocities compared to age and gender normative data. No such relationship was observed in the control group of heathy subjects. In patients with one-sided dislocation, no differences were found in knee flexors peak torque, torque at 30 degrees of knee flexion, angle of peak torque or H/Q ratio between the healthy and affected limbs for either angular velocity. Conclusions In patients with recurrent patellar dislocation, knee flexors strength is decreased significantly in both the unaffected and affected limbs. This may indicate a constitutional weakening of these muscles which can predispose to recurrent dislocations. Trial registration The study was retrospectively registered on ClinicalTrials.gov (NCT04838158), date of registration; 22/03/2021.
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21
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Abstract
Patella dislocation is one of the most common knee injuries, accounting for 3% of acute knee injuries. Despite its prevalence, patella dislocation is often missed, with a haemarthrosis often the only sign, albeit a non-specific one. A thorough history and examination are necessary to identify patella dislocation and its potential causes. Investigations should include cross-sectional imaging to evaluate both osseous and soft tissue structures in order to guide management. Management in the acute setting is normally non-operative, but damage to structural supports, osteochondral defects or recurrent dislocation should prompt consideration of operative treatment. Operative treatment should address the soft tissue stabilisers and/or osseus deformities that predispose to, or occur secondary to, patella dislocation.
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Affiliation(s)
- Kwaku Baryeh
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, Surrey, UK
| | - Fanuelle Getachew
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, Surrey, UK
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22
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Reddy AK, Anderson JM, Gray HM, Fishbeck K, Vassar M. Clinical Trial Registry Use in Orthopaedic Surgery Systematic Reviews. J Bone Joint Surg Am 2021; 103:e41. [PMID: 33983151 DOI: 10.2106/jbjs.20.01743] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Results from systematic reviews and meta-analyses, which have the highest level of evidence (Level I), often drive clinical decision-making and health policy. Often, unpublished trial data are omitted from systematic reviews, raising concerns about the extent of the reliability and validity of results that have been drawn from systematic reviews. We aimed to determine the extent to which systematic review authors include searches of clinical trial registries for unpublished data when conducting systematic reviews in orthopaedic surgery. METHODS Systematic reviews and/or meta-analyses were gathered from the top 5 orthopaedic surgery journals based on the h5-index from Google Scholar Metrics. Systematic reviews that had been published in the Cochrane Database of Systematic Reviews, which requires the inclusion of a clinical trial registry search, served as controls. For the primary outcome, each systematic review from the top 5 orthopaedic journals was screened to determine whether the authors of each study searched for unpublished data in clinical trial registries. We then compared the rate of registry searches with those in the control group. For the secondary analysis, a search of ClinicalTrials.gov was performed for unpublished trial data for 100 randomized systematic reviews. RESULTS All 38 of the Cochrane systematic reviews (100%) included clinical trial registry searches, while the top 5 orthopaedic journals had only 31 of 480 studies (6.5%) that looked at clinical trial registries. The secondary analysis yielded 59 of 100 systematic review articles (59.0%) that could have included unpublished clinical trial data from ≥1 studies to their sample. CONCLUSIONS Systematic reviews that have been published in the top orthopaedic surgery journals seldom included a search for unpublished clinical trial data. CLINICAL RELEVANCE The exclusion of clinical trial registry searches potentially contributes to publication bias within the orthopaedic literature. Moving forward, systematic review authors should include clinical trial registry searches for unpublished clinical trial data to provide the most accurate representation of the available evidence for systematic reviews and meta-analyses.
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Affiliation(s)
- Arjun K Reddy
- Office of Medical Student Research (A.K.R., J.M.A., H.M.G., and M.V.) and Department of Psychiatry and Behavioral Sciences (M.V.), Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - J Michael Anderson
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Harrison M Gray
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Keith Fishbeck
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Matt Vassar
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
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McFarlane KH, Coene RP, Feldman L, Miller PE, Heyworth BE, Kramer DE, Kocher MS, Yen YM, Milewski MD. Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients. J Child Orthop 2021; 15:149-156. [PMID: 34040661 PMCID: PMC8138795 DOI: 10.1302/1863-2548.15.200225] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. METHODS The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. RESULTS Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. CONCLUSION This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kelly H. McFarlane
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US
| | - Ryan P. Coene
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US
| | - Lanna Feldman
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US
| | - Patricia E. Miller
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US
| | - Benton E. Heyworth
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US
| | - Dennis E. Kramer
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US
| | - Mininder S. Kocher
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US
| | - Yi-Meng Yen
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US
| | - Matthew D. Milewski
- Boston Children’s Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, MA, US,Harvard Medical School, Boston, MA, US,Correspondence should be sent to Matthew D. Milewski, Boston Children’s Hospital, Orthopaedic Surgery & Sports Medicine, 300 Longwood Avenue, Boston, MA 02115, US.
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Bailey MEA, Metcalfe A, Hing CB, Eldridge J. Consensus guidelines for management of patellofemoral instability. Knee 2021; 29:305-312. [PMID: 33677155 DOI: 10.1016/j.knee.2021.02.018] [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: 11/22/2020] [Revised: 01/20/2021] [Accepted: 02/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this consensus process was to provide robust national guidelines to assist with decision making with regards to surgical management of patellofemoral instability. METHODS A national group of surgeons, physiotherapists, basic scientists and a radiologist with expert experience in patellofemoral instability was convened. A formal consensus process was undertaken using validated methodology. They reviewed the existing literature, performed a group consensus meeting to develop recommendations and followed this with a wider consultation meeting with an open invitation for final ratification. The guidelines were reviewed and authorised by the BASK executive committee, followed by the British Orthopaedic Association prior to final publication. RESULTS The review of the literature confirmed a significant absence of an evidence base to guide clinicians in the surgical management of patellofemoral instability. The consensus process outlined guidance relating to diagnosis and clinical assessment, appropriate imaging modalities, recommendations for surgical options and appropriate post operative physiotherapy. Following wide invitation to contribute to the final document, 102 people responded. Twenty six of those provided additional comments which were blinded, discussed and included or excluded following further discussion amongst the working group. CONCLUSION Patellofemoral instability is a complex pathology with multiple surgical options available to those who decide surgery is indicated. In the absence of a strong evidence base, these guidelines aim to assist with that decision making process and will pave the way for more robust clinical trials in the future.
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Affiliation(s)
| | - Andrew Metcalfe
- University Hospitals Coventry and Warwickshire NHS Trust, United Kingdom
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25
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Abdel-Aziz A, Sherif MM, Waly MR, Abdel-Aziz MA, Mostafa Zaky Abdelrazek BH. Simple Cost-Effective Reinsertion of Avulsed Medial Patellofemoral Ligament in Acute Patellar Dislocation. Arthrosc Tech 2021; 10:e847-e853. [PMID: 33738223 PMCID: PMC7953263 DOI: 10.1016/j.eats.2020.10.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 10/29/2020] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement in the first 20° of flexion and is disrupted after patellar subluxation or dislocation. Management of acute patellar dislocations is controversial, and many clinicians opt for conservative treatment in the acute phase. However, a traumatic rupture of the MPFL warrants surgical attention. Several considerations must be made by surgeons attempting reinsertion of the MPFL, including the choice of implant and timing of surgery, to restore the anatomy and biomechanics of the patellofemoral joint. Our aim is to achieve robust reinsertion of the MPFL restoring the anatomy and biomechanics of the patellofemoral joint using a simple, reproducible, and economical technique. We present MPFL reinsertion to the medial border of the patella in an acute patellar dislocation with a braided No. 2 ultrahigh-molecular-weight polyethylene suture (No. 2 Ultrabraid; Smith & Nephew, Memphis, TN) that is passed through 3 transverse parallel tunnels and tied over a bone bridge on the lateral border of the patella. This technique is simple with no implanted hardware, does not have the risk of donor-site morbidity of MPFL reconstruction, and can be performed in skeletally immature patients without growth plate concerns.
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Affiliation(s)
- Ahmed Abdel-Aziz
- Trauma and Orthopaedics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Mamdouh Sherif
- Trauma and Orthopedics, El Sahel Teaching Hospital, Cairo, Egypt,Address correspondence to Mohamed Mamdouh Sherif, M.Sc., M.D., Trauma and Orthopedics, El Sahel Teaching Hospital, 2 Youssef Karam, El Sahel, Cairo 11697.
| | | | - Mahmoud Ahmed Abdel-Aziz
- Trauma and Orthopaedics, Faculty of Medicine, Cairo University, Cairo, Egypt,Student Hospital, Cairo University, Cairo, Egypt
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26
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Why compromise the patella? Five-year follow-up results of medial patellofemoral ligament reconstruction with soft tissue patellar fixation. INTERNATIONAL ORTHOPAEDICS 2021; 45:1493-1500. [PMID: 33386924 PMCID: PMC8178154 DOI: 10.1007/s00264-020-04922-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/17/2020] [Indexed: 10/27/2022]
Abstract
PURPOSE This study investigates the redislocation rate and functional outcome at a minimum follow-up of five years after medial patellofemoral ligament (MPFL) reconstruction with soft tissue patellar fixation for patella instability. METHODS Patients were retrospectively identified and knees were evaluated for trochlea dysplasia according to Dejour, for presence of patella alta and for presence of cartilage lesion at surgery. At a minimum follow-up of five years, information about an incident of redislocation was obtained. Kujala, Lysholm, and Tegner questionnaires as well as range of motion were used to measure functional outcome. RESULTS Eighty-nine knees were included. Follow-up rate for redislocation was 79.8% and for functional outcome 58.4%. After a mean follow-up of 5.8 years, the redislocation rate was 5.6%. There was significant improvement of the Kujala score (68.8 to 88.2, p = 0.000) and of the Lysholm score (71.3 to 88.4, p = 0.000). Range of motion at follow-up was 149.0° (115-165). 77.5% of the knees had patella alta and 52.9% trochlear dysplasia types B, C, or D. Patellar cartilage legions were present in 54.2%. Redislocations occurred in knees with trochlear dysplasia type C in combination with patella alta. CONCLUSION MPFL reconstruction with soft tissue patellar fixation leads to significant improvement of knee function and low midterm redislocation rate. Patients with high-grade trochlear dysplasia should be considered for additional osseous correction.
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Sochacki KR, Shea KG, Varshneya K, Safran MR, Abrams GD, Donahue J, Sherman SL. Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review. Am J Sports Med 2021; 49:261-266. [PMID: 32109145 DOI: 10.1177/0363546520904685] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies. PURPOSE To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants. STUDY DESIGN Systematic review. METHODS A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage. RESULTS Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm. CONCLUSION The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.
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Affiliation(s)
- Kyle R Sochacki
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Kunal Varshneya
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Donahue
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
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28
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Black SR, Meyers KN, Nguyen JT, Green DW, Brady JM, Maher SA, Shubin Stein BE. Comparison of Ligament Isometry and Patellofemoral Contact Pressures for Medial Patellofemoral Ligament Reconstruction Techniques in Skeletally Immature Patients. Am J Sports Med 2020; 48:3557-3565. [PMID: 33135907 DOI: 10.1177/0363546520966609] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adult medial patellofemoral ligament (MPFL) reconstruction techniques are not appropriate for the skeletally immature patient given the proximity of the distal femoral physis. Biomechanical consequences of reconstructions aimed at avoiding the physis have not been adequately studied. PURPOSE To quantify the biomechanical effects of MPFL reconstruction techniques intended for skeletally immature patients. STUDY DESIGN Controlled laboratory study. METHODS Four MPFL reconstruction techniques were evaluated using a computationally augmented cadaveric model: (1) Schoettle point: adult-type reconstruction; (2) epiphyseal: socket distal to the femoral physis; (3) adductor sling: graft wrapped around the adductor tendon; (4) adductor transfer: adductor tendon transferred to patella. A custom testing frame was used to cycle 8 knees for each technique from 10° to 110° of flexion. Patellofemoral kinematics were recorded using a motion camera system, contact stresses were recorded using Tekscan pressure sensors, and MPFL length was computed using an inverse kinematics computational model. Change in MPFL length, patellar facet forces, and patellar kinematics were compared using generalized estimating equation modeling. RESULTS Schoettle point reconstruction was the most isometric, demonstrating isometry from 10° to 100°. The epiphyseal technique was isometric until 60°, after which the graft loosened with increasing flexion. The adductor sling and adductor transfer techniques were significantly more anisometric from 40° to 110°. Both grafts tightened with knee flexion and resulted in significantly more lateral patellar tilt versus the intact state in early flexion and significantly higher contact forces on the medial facet versus the epiphyseal technique in late flexion. CONCLUSION In this cadaveric simulation, the epiphyseal technique allowed for a more isometric ligament until midflexion, when the patella engaged within the trochlear groove. The adductor sling and adductor transfer grafts became tighter in flexion, resulting in potential loss of motion, pain, graft stretching, and failure. Marginal between-condition differences in patellofemoral contact mechanics and patellar kinematics were observed in late flexion. CLINICAL RELEVANCE In the skeletally immature patient, using an epiphyseal type MPFL reconstruction with the femoral attachment site distal to the physis results in a more isometric graft compared with techniques with attachment sites proximal to the physis.
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Affiliation(s)
| | | | | | - Daniel W Green
- Hospital for Special Surgery, New York City, New York, USA
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Johnston TR, Liles J, Riboh J. Anchor-Based Femoral Fixation for Physeal-Sparing Medial Patellofemoral Ligament Reconstruction: A Time-Zero Biomechanical Comparison With Tenodesis Screw Fixation. Am J Sports Med 2020; 48:3021-3027. [PMID: 32909820 DOI: 10.1177/0363546520951523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Open physes and trochlear/notch geometries in pediatric patients limit the safe corridor for femoral interference screw graft fixation during medial patellofemoral ligament (MPFL) reconstruction. Accordingly, interest is increasing in anchor-based fixation, but biomechanical validation is deficient. PURPOSE To compare anchor-based and tenodesis screw femoral fixation of MPFL grafts in a time-zero biomechanical model. STUDY DESIGN Controlled laboratory study. METHODS Twenty-seven fresh-frozen porcine distal femurs were potted for testing in an electromechanical load frame, while bovine tendons were used for MPFL grafts. Reconstructions were performed with 1 of 3 femoral fixation strategies: 4.5-mm biocomposite double-loaded threaded anchor (DLA group), 3.9-mm biocomposite knotless threaded anchor (KA group), or traditional 7 × 23-mm biocomposite tenodesis screw (TS group). For testing, femoral specimens were oriented and secured in the mechanical testing apparatus such that actuator tensile pull re-created the normal MPFL trajectory. Specimens underwent 10 cycles of 5- to 15-N loading at 1-Hz preconditioning, followed by 1000 cycles of 10- to 50 N-loading at 1 Hz. After cyclic loading, all specimens were loaded to failure at 305 mm/min. The average cyclic construct stiffness, displacement, and load-to-failure data between the 3 groups were compared using analysis of variance (ANOVA) with the significance level set at P < .05. RESULTS Average cyclic construct stiffnesses were comparable across groups per repeated-measures ANOVA analysis: 68.3 ± 6.3, 71.4 ± 6.4, and 74.3 ± 7.9 N/mm for TS, DLA, and KA groups, respectively (at cycle 1000). Average construct displacements at cycles 100 and 1000 were significantly less in the anchor versus tenodesis screw groups per ANOVA and Tukey post hoc analysis: 7.7 ± 4.2 mm for the TS group versus 3.7 ± 0.4 and 4.3 ± 0.6 mm for the DLA and KA groups, respectively (at cycle 1000). There was no significant difference in ultimate failure loads between the anchor and tenodesis screw groups, but 3 of 9 TS constructs failed at loads below the average failure load of the native MPFL. CONCLUSION Compared with the tenodesis group, anchor-based fixation produced constructs with equivalent cyclic stiffnesses, improved load-displacement characteristics, and had less failure load variability in the porcine cadaveric model. CLINICAL RELEVANCE Femoral fixation of the MPFL graft with a single anchor (4.5 or 3.9 mm threaded) is a viable alternative to traditional tenodesis screw fixation.
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Affiliation(s)
- Tyler Robert Johnston
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jordan Liles
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan Riboh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Zhang K, Jiang H, Li J, Fu W. Comparison Between Surgical and Nonsurgical Treatment for Primary Patellar Dislocations in Adolescents: A Systematic Review and Meta-analysis of Comparative Studies. Orthop J Sports Med 2020; 8:2325967120946446. [PMID: 33015209 PMCID: PMC7513014 DOI: 10.1177/2325967120946446] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Whether surgical or nonsurgical management is more appropriate for primary
patellar dislocations (PPDs) in adolescents (younger than 18 years) remains
controversial. Purpose: To compare the clinical outcomes of surgical versus nonsurgical treatment for
adolescents and children with PPDs. Study Design: Systematic review; Level of evidence, 3. Methods: There were 2 reviewers who independently searched the PubMed, Embase, Ovid,
and Cochrane databases for English-language studies of randomized controlled
trials (RCTs), quasi-RCTs, and observational studies comparing surgical with
nonsurgical treatment for PPDs. The primary outcomes were redislocations,
the Kujala score, and the Knee injury and Osteoarthritis Outcome Score
(KOOS), and the secondary outcome was subsequent surgery. Results: A total of 6 studies were included in our systematic review and
meta-analysis. Among patients younger than 18 years, surgery was associated
with a lower redislocation rate compared with nonsurgical treatment within 5
years of treatment (risk ratio [RR], 0.58 [95% CI, 0.37-0.91];
P = .02; I2 = 47%) but not beyond 5 years (RR, 0.80 [95% CI, 0.59-1.07];
P = .14; I2 = 34%). However, surgery resulted in worse Kujala and KOOS
scores compared with nonsurgical treatment. Yet, the treatment difference
between the 2 groups tended to decrease over time. Conclusion: The available evidence suggests that for adolescents with PPDs, surgery was
superior to nonsurgical treatment in the short term to reduce the
redislocation rate but resulted in poorer outcomes of knee function based on
the Kujala and KOOS scores. However, the superiority of either surgical or
nonsurgical treatment in adolescents did not appear to persist in the long
term.
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Affiliation(s)
- Kaibo Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Jiang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Instabile Patella des Erwachsenen. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00405-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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32
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An VV, Sivakumar BS, Phan K, Fritsch BA, Sher D. Isolated versus combined medial patellofemoral ligament reconstruction for lateral instability of the patella. J Orthop Surg (Hong Kong) 2020; 27:2309499018820698. [PMID: 30798706 DOI: 10.1177/2309499018820698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Medial patellofemoral ligament reconstruction (MPFLR) is regularly combined with a tibial tuberosity transfer (TTT) in cases of recurrent patellar instability with underlying structural deformity. However, these indications for a TTT have recently come into question. This study aimed to assess the traditional indications by comparing the outcomes of isolated and combined MPFLR for the treatment of recurrent lateral patellar dislocation. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies were those which reported the outcomes of either isolated or combined or both MPFLR. Studies were required to report at least one of the following: redislocation rate, revision due to instability, or the Kujala score. RESULTS We found no difference between isolated and combined MPFLR in terms of redislocation ( p = 0.48), revisions due to instability ( p = 0.36), positive apprehension tests ( p = 0.25), or the Kujala score ( p = 0.58). Combined reconstruction presented more complications compared to isolated procedures ( p = 0.05). Subgroup analysis revealed no significant difference between studies investigating isolated medial patellofemoral ligament reconstruction MPFLR performed in patients with normal tibial tuberosity-trochlear groove (TT-TG) distances only or in patients with both normal and elevated TT-TG distances. CONCLUSIONS According to the published data, there is no difference in outcomes between isolated and combined MPFLR. Underlying structural deformity did not demonstrate any significant effect on the success of the isolated MPFLR. Although there are definite indications for combined reconstruction, the current evidence suggests that our inclusion criteria may not be entirely correct. Further study is required to clarify and refine the true indications for combined MPFLR. LEVEL OF EVIDENCE III, meta-analysis of nonrandomized studies.
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Affiliation(s)
- Vincent Vg An
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- 2 Department of Orthopaedics, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Kevin Phan
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brett A Fritsch
- 3 Department of Orthopaedics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Doron Sher
- 4 Department of Orthopaedics, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Sidharthan S, Wang G, Schlichte LM, Fulkerson JP, Green DW. Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients. JBJS Essent Surg Tech 2020; 10:ST-D-18-00110. [PMID: 32368409 DOI: 10.2106/jbjs.st.18.00110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Patellofemoral instability is a common problem affecting children and adolescents, with recurrent instability often requiring surgical intervention. Medial patellofemoral ligament (MPFL) reconstruction has become a mainstay for the treatment of patellofemoral instability because of the biomechanical importance of the MPFL against lateral dislocation as well as the high frequency of MPFL injury following traumatic patellar dislocation. The concern in managing skeletally immature patients is the potential for injury to the distal femoral physis. Here, we highlight 2 techniques for MPFL reconstruction. The first technique utilizes a hamstring autograft. The steps include: Step 1: Harvest the semitendinosus graft from a 2-cm posteromedial incision with use of an open tendon harvester proximally and a closed tendon harvester distally. Step 2: Prepare the graft for double-bundle reconstruction, allowing for approximately 50 to 60 mm for the reconstructed MPFL and 15 to 20 mm for graft placement within the patella and femoral sockets. Step 3: Use a guidewire and reamer to create 2 patellar sockets approximately 15 mm long each. Step 4: Use a guidewire under fluoroscopy to position and create a femoral socket distal to the distal femoral physis approximately 15 mm long. Step 5: Fix the graft on the femur with use of a tenodesis screw, pass the graft through the soft-tissue space between the fascia and synovium to the superior half of the patella, then dock the free ends of the graft onto the 2 patellar sockets with "PEEK (polyetheretherketone) SwiveLocks (Arthrex)" while the knee is in 30° of flexion. We also review a second technique of docking the hamstring graft onto the adductor tubercle and suturing it proximally to the deep distal medial aspect of the quadriceps tendon. Although only a limited number of studies have reported the outcomes of MPFL reconstruction in skeletally immature patients, such studies have demonstrated a high return to preoperative level of sports activity and a reduced prevalence of recurrent patellar instability.
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Affiliation(s)
- Sreetha Sidharthan
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Grace Wang
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Lindsay M Schlichte
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - John P Fulkerson
- Orthopedic Associates of Hartford, Hartford, Connecticut.,Departments of Orthopaedic Surgery and Anatomy, University of Connecticut Medical School, Farmington, Connecticut
| | - Daniel W Green
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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Mehl J, Otto A, Comer B, Kia C, Liska F, Obopilwe E, Beitzel K, Imhoff AB, Fulkerson JP, Imhoff FB. Repair of the medial patellofemoral ligament with suture tape augmentation leads to similar primary contact pressures and joint kinematics like reconstruction with a tendon graft: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc 2020; 28:478-488. [PMID: 31410528 DOI: 10.1007/s00167-019-05668-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero. METHODS A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N. RESULTS There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm2 vs. 108.7 ± 36.6 mm2; p = 0.040), for PT at 10° knee flexion and 2 N preload (- 1.9 ± 2.5° vs. - 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (- 0.8 ± 2.5° vs. - 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics. CONCLUSIONS Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics.
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Affiliation(s)
- Julian Mehl
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA.,Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Alexander Otto
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Brendan Comer
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Franz Liska
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - John P Fulkerson
- Orthopaedic Associates of Hartford, 499 Farmington Avenue, Farmington, CT, 06032, USA
| | - Florian B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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Combined medial and lateral patellar retinaculum plasty for skeletally immature patients with patellar dislocation and low-grade trochlear dysplasia. Knee 2020; 27:9-17. [PMID: 31864659 DOI: 10.1016/j.knee.2019.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/08/2019] [Accepted: 11/26/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND To evaluate the clinical outcomes of combined medial and lateral patellar retinaculum plasty for skeletally immature patients with patellar dislocation and low-grade trochlear dysplasia. METHODS From December 2014 to December 2016, we reviewed 19 skeletally immature patients who underwent medial and lateral patellar retinaculum plasty at our institution. Clinical evaluations were performed pre- and postoperatively, and included determination of the number of patellar re-dislocation patients, the Kujala and Tegner scores, the patellar tilt angle, lateral patellar shift, and congruence angle. The radiographic evaluation parameters were measured on computed tomography scans. RESULTS No dislocation or subluxation occurred during the mean follow-up of 35.42 months (24-48 months). Postoperatively, the Kujala score improved from 57.6 ± 4.2 to 86.9 ± 8.1 (P < 0.05), and the Tegner activity score improved from 2.6 ± 1.0 to 5.0 ± 1.3 (P < 0.05). Radiographically, the patellar tilt angle decreased from 32.7 ± 5.9° to 13.4 ± 4.28° (P < 0.05), the lateral patellar shift decreased from 15.9 ± 1.1 mm to 8.4 ± 0.6 mm (P < 0.05), and the congruence angle decreased from 29.9 ± 15.3° to -9.6 ± 15.5° (P < 0.05). CONCLUSIONS Medial and lateral patellar retinaculum plasty is a promising procedure that has the advantage of being a simple operation that induces little trauma. It is a good treatment option for skeletally immature patients with patellar dislocation who have low-grade trochlear dysplasia.
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Mochizuki T, Tanifuji O, Sato T, Watanabe S, Omori G, Endo N. Scoring system for optimal management of acute traumatic patellar dislocation: A multicenter study. J Orthop Sci 2020; 25:173-177. [PMID: 30928034 DOI: 10.1016/j.jos.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/22/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND In first-time acute traumatic patellar dislocations, numerous anatomic and clinical factors are complicatedly associated and should be comprehensively considered for the optimal management of conservative or surgical intervention. The purpose of this study was to establish a scoring system, using a concept that is not complicated and easily used in clinic. METHODS Of 131 first-time acute traumatic patellar dislocations, 81 patients (51 females, 30 males) with an average age of 19.6 (95%CI, 17.5-21.6) years and an average follow-up duration of 17.1 (95% CI, 12.3-21.9) months, who underwent conservative treatment after first-time dislocations, were reviewed. Based on the odds ratios applying logistic regression analysis, the scoring system was established. RESULTS The scoring system (total: 10 points) had simple composition of age <20 (2 points), sports injury (1 points), hemarthrosis (1 points), and image findings of a bony fragment (3 points), lateral shift of the patella (1 points), and trochlear dysplasia (2 points). A threshold score of 6.5 was determined using the area under receiver operating characteristic curve of 0.893 (p < 0.0001). In logistic regression analysis, a score of ≥7 was shown to be a dominant factor for recurrence (OR = 27.1, p < 0.0001). Furthermore, the association between the score and recurrence risk was as follows: a score of ≤4 = low risk (1/21 cases, 5%); a score of 5-7 = medium risk (13/27 cases, 48%); a score of ≥8 = high risk (30/33 cases, 91%). CONCLUSIONS Based on the simple scoring system, patients who scored ≥8 were considered suitable for surgical treatment because of the high rate of recurrence, whereas those who scored ≤4 were considered suitable for conservative treatment because of the low rate of recurrence.
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Affiliation(s)
- Tomoharu Mochizuki
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan.
| | - Osamu Tanifuji
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan.
| | - Takashi Sato
- Department of Orthopaedic Surgery, Niigata Medical Center, Niigata, Japan.
| | - Satoshi Watanabe
- Department of Orthopaedic Surgery, Niigata Medical Center, Niigata, Japan.
| | - Go Omori
- Department of Health and Sports, Faculty of Health Sciences, Niigata University of Health and Welfare, Niigata, Japan.
| | - Naoto Endo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan.
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Pilone C, Bonasia DE, Rosso F, Cottino U, Mazzola C, Blonna D, Rossi R. Medial Patellofemoral Ligament Reconstruction and Nonanatomic Stabilization Techniques in Skeletally Immature Patients. JOINTS 2019; 7:98-106. [PMID: 34195537 PMCID: PMC8236322 DOI: 10.1055/s-0039-3400451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 10/15/2019] [Indexed: 11/06/2022]
Abstract
Patellar instability is a common cause of knee disability in children and adolescent, with a high recurrence rate. When conservative treatment fails, surgical options should be considered. The femoral insertion of the medial patellofemoral ligament (MPFL) is in close proximity to the distal femoral growth plate and precautions should be taken to avoid injuries to the physis. Anatomical features of the MPFL complex, with focus on the relationship between femoral MPFL attachment and femoral physis, are discussed together with surgical tips to avoid injuries to the growth plates. The aim of this article is to review the recent literature regarding MPFL reconstruction and other stabilization techniques for patellofemoral instability in skeletally immature patients, focusing on the different surgical options available. These can be classified as anatomical versus nonanatomical, proximal versus distal realignments, or based on the graft used: free graft and pedicled graft (quadriceps, patellar tendon, hamstring, and adductor magnus).
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Affiliation(s)
- Carola Pilone
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Davide Edoardo Bonasia
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Federica Rosso
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Umberto Cottino
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Claudio Mazzola
- SC Ortopedia Delle Articolazioni, Ospedali Galliera Genova, Genoa, Italy
| | - Davide Blonna
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Roberto Rossi
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
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Abstract
Patellofemoral instability is a common orthopedic condition in children and adolescents, with recurrent instability often requiring surgical intervention. Age, bilateral instability, and various anatomic features such as trochlear dysplasia, patella alta, increased tibial tubercle to trochlear groove distance, and patellar tilt have all been described as risk factors for recurrent patellar instability. Medial patellofemoral ligament reconstruction has become the mainstay of treatment for addressing recurrent patellar instability in skeletally immature patients. For some patients, additional interventions such as distal realignment and guided growth procedures may be required to address anatomic pathology. This article discusses various risk factors associated with patellofemoral instability, reconstruction techniques, and a case example.
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Uppstrom TJ, Price M, Black S, Gausden E, Haskel J, Green DW. Medial patellofemoral ligament (MPFL) reconstruction technique using an epiphyseal femoral socket with fluoroscopic guidance helps avoid physeal injury in skeletally immature patients. Knee Surg Sports Traumatol Arthrosc 2019; 27:3536-3542. [PMID: 30852626 DOI: 10.1007/s00167-019-05412-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to assess the physeal safety associated with the use of an epiphyseal femoral socket for paediatric medial patellofemoral ligament (MPFL) reconstruction. METHODS Fifty-four knees in 49 skeletally immature patients underwent physeal-sparing MPFL reconstruction performed by 1 surgeon at a tertiary care academic medical centre from 2007 to 2016. A femoral socket distal to the femoral physis was used for graft fixation in all the patients. To assess physeal safety, all included patients either had post-operative MRIs of the operative knee or standing hip-to-ankle radiographs. Physeal safety was assessed on MRI, and the distance between the femoral socket relative to the physis was measured at both the aperture and the end of the socket. Development of lower limb angular deformities and/or limb length discrepancy (LLD) was evaluated using post-operative standing hip-to-ankle radiographs, patient records, and clinical assessments. RESULTS The mean age at time of surgery was 13.3 ± 1.6 years. The median length of radiographic follow-up was 2.2 years (range 1.0-5.7 years). At most recent clinical follow-up, five patients (9.3%) had recurrent patellar instability, with three patients (5.6%) undergoing subsequent tibial tubercle osteotomy or revision MPFL reconstruction. There was no statistically significant difference in leg length between operated and non-operated extremities (n.s.). There was no statistically significant difference between non-operated and operated mMPTA (n.s.) and mLDFA (n.s.) measurements. On post-operative MRI, there was no evidence of physeal arrest. The median distance from the physis to the socket at the aperture and distal end of the femoral socket were 5.9 mm (range 1.9-12) and 7.1 mm (1.3-12.4), respectively. CONCLUSION These results demonstrate that with fluoroscopic guidance, placing the femoral socket distal to the distal femoral physis is an effective method for avoiding physeal injury and subsequent growth disturbances in children with patellar instability. Clinically, this information is essential in optimal surgical management of these patients, as this technique allows for femoral fixation of the MPFL reconstruction graft within the epiphysis while also preserving normal growth. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Tyler J Uppstrom
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.,Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Meghan Price
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Sheena Black
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Elizabeth Gausden
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Jonathan Haskel
- Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Daniel W Green
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA.
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Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population. Arthroscopy 2019; 35:2909-2915. [PMID: 31604512 DOI: 10.1016/j.arthro.2019.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 04/09/2019] [Accepted: 05/01/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE To comparatively evaluate the clinical outcomes and rates of recurrent instability in young patients with primary medial patellofemoral ligament (MPFL) repair or reconstruction, as well as to assess for radiologic risk factors for worse outcomes. METHODS A retrospective review identified all patients with lateral patellar instability who underwent either MPFL repair and/or imbrication or MPFL reconstruction without any additional osseous procedures between 2008 and 2015 at a single center. Demographic variables and preoperative magnetic resonance imaging were analyzed, and Kujala scores were obtained at a minimum 2-year follow-up. Risk factors for worse outcomes were assessed, including the Caton-Deschamps Index (CDI) Insall-Salvati Index, tibial tubercle-trochlear groove distance, and tibial tubercle-posterior cruciate ligament distance. RESULTS We identified 51 knees with isolated MPFL surgery (reconstruction in 32 and imbrication and/or repair in 19) at a mean of 59.7 months' follow-up (range, 24-121 months). The overall rate of recurrent dislocations was significantly greater in the repair group (36.9%) versus the reconstruction group (6.3%, P = .01), despite the average CDI being significantly higher in the reconstruction group (1.34 vs 1.23 in repair group, P = .04). No significant difference in the rate of return to baseline activity was found between the groups (77.8% in reconstruction group vs 70% in repair group, P = .62). The average Kujala score showed no significant difference between the repair and reconstruction groups (84.15 ± 14.2 vs 84.83 ± 14.38, P = .72). No imaging measurements were found to be predictive of a worse postoperative Kujala score; however, the average CDI among the MPFL repair failures (1.30 ± 0.05) was significantly higher than among the MPFL repair nonfailures (1.18 ± 0.12, P = .03). CONCLUSIONS MPFL reconstruction may provide improved midterm clinical outcomes and a decreased recurrence rate compared with MPFL repair. Increased patellar height as measured by the CDI may be a risk factor for recurrent patellar instability in patients who undergo isolated MPFL repair. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Gruskay JA, Strickland SM, Casey E, Chiaia TA, Green DW, Gomoll AH. Team Approach: Patellofemoral Instability in the Skeletally Immature. JBJS Rev 2019; 7:e10. [PMID: 31365447 DOI: 10.2106/jbjs.rvw.18.00159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jordan A Gruskay
- Departments of Orthopedics (J.A.G., S.M.S., D.W.G., and A.H.G.), Physiatry (E.C.), and Sports Rehabilitation (T.A.C.), Hospital for Special Surgery, New York, NY
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Pagliazzi G, Napoli F, Previtali D, Filardo G, Zaffagnini S, Candrian C. A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation. Arthroscopy 2019; 35:2469-2481. [PMID: 31395189 DOI: 10.1016/j.arthro.2019.03.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/17/2019] [Accepted: 03/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE II, meta-analysis of level I and level II randomized clinical trials.
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Affiliation(s)
- Gherardo Pagliazzi
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Francesca Napoli
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland; Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
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Yang F, Guo W, Wang Q, Zhu Z, Guan C, Zhao S, Yuan B. Surgical versus nonsurgical treatment of primary acute patellar dislocation: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16338. [PMID: 31335681 PMCID: PMC6708831 DOI: 10.1097/md.0000000000016338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND To systematically review the efficacy of surgical versus nonsurgical treatment for acute patellar dislocation. MATERIALS AND METHODS PubMed, Cochrane, and Embase were searched up to February 12, 2019. After removing duplicates, preliminary screening, and reading the full texts, we finally selected 16 articles, including 11 randomized controlled trials and 5 cohort studies. The quality of the enrolled studies was evaluated by Jadad score or Newcastle-Ottawa scale. Meta-analyses were performed using odds ratio (OR) and standardized mean difference (SMD) as effect variables. The clinical parameters assessed included mean Kujala score, rate of redislocation, incidence of patellar subluxation, patient satisfaction, and visual analog scale (VAS) for pain. Evidence levels were determined using GRADE profile. RESULTS The 16 included studies involved 918 cases, 418 in the surgical group and 500 in the nonsurgical group. The results of the meta-analysis showed higher mean Kujala score (SMD = 0.79, 95% confidence interval [CI] [0.3, 1.28], P = .002) and lower rate of redislocation (OR = 0.44, 95% CI [0.3, 0.63], P < .00001) in the surgical group than the nonsurgical group, but showed insignificant differences in the incidence of patellar subluxation (OR = 0.61, 95% CI [0.36, 1.03], P = .06), satisfaction of patients (OR = 1.44, 95% CI [0.64, 3.25], P = .38), and VAS (SMD = 0.84, 95% CI [-0.36, 9.03], P = .84). CONCLUSION For patients with primary acute patellar dislocation, surgical treatment produces a higher mean Kujala score and a lower rate of redislocation than nonsurgical treatment.
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Affiliation(s)
- Fan Yang
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Wenlai Guo
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center
| | - Qian Wang
- Otolaryngology Head and Neck Surgery. The First Hospital of Jilin University, Changchun, China
| | - Zhe Zhu
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center
| | - Congying Guan
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Shishun Zhao
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Baoming Yuan
- Department of Orthopedics. The Second Hospital of Jilin University
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Hiemstra LA, Kerslake S. Age at Time of Surgery but Not Sex Is Related to Outcomes After Medial Patellofemoral Ligament Reconstruction. Am J Sports Med 2019; 47:1638-1644. [PMID: 31063706 DOI: 10.1177/0363546519841371] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction has become a well-accepted procedure for recurrent patellofemoral instability. Despite a growing volume of research assessing surgical results, the relationship of age and sex to outcomes after MPFL reconstruction surgery is unclear. PURPOSE To investigate whether age at the time of surgery or sex influenced patient-reported quality of life and clinical outcome after MPFL reconstruction for recurrent lateral patellofemoral instability. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between January 2010 and May 2016, 328 patients underwent primary patellofemoral stabilization. Demographic and clinical data were collected preoperatively. Patients completed the Banff Patellofemoral Instability Instrument (BPII) at the pre- and postoperative visits and were assessed clinically at 12 and 24 months. To assess the effects of age at surgery and sex on BPII, multiple linear regression models were fit predicting BPII at 12 and 24 months. An unadjusted regression was applied with the predictors being age at the time of surgery and sex. A second regression model was applied adjusting for age at first dislocation, grade of trochlear dysplasia, knee hyperextension, and the WARPS/STAID score-a measure of the risky patellofemoral instability characteristics of the patient. RESULTS Of 328 patients, 298 (91%) had complete data and minimum 12-month BPII scores available for analysis. There were 11 redislocations in the cohort (3.4%), all in female patients. When stratified by sex, baseline characteristics were not statistically different except for higher age at first dislocation ( P = .022) as well as higher WARPS/STAID scores ( P = .006) for males. Age at the time of surgery was statistically significant for each postoperative follow-up, with lower BPII scores apparent for each 10-year increase in age at the time of surgery. In the adjusted model, the WARPS/STAID score was significantly associated with the preoperative BPII score. For the 24-month postoperative BPII scores, age at time of surgery and preoperative WARPS/STAID score were both significant. Lower BPII scores were apparent for each 10-year increase in age at the time of surgery, as well as for lower scores on the WARPS/STAID classification. CONCLUSION This study demonstrated that when adjusted for risky pathoanatomy, neither age at first dislocation nor sex influences patient-reported quality of life outcomes after MPFL reconstruction. Age at the time of surgery was correlated with outcome, with lower BPII scores apparent for each 10-year increase in age at the time of MPFL reconstruction.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine, Banff, Alberta, Canada.,Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Osteochondral allograft for failed mosaicplasty in adolescent female with large patellar defect. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rosinski A, Chakrabarti M, Gwosdz J, McGahan PJ, Chen JL. Double-Bundle Medial Patellofemoral Ligament Reconstruction With Allograft. Arthrosc Tech 2019; 8:e513-e520. [PMID: 31194129 PMCID: PMC6552203 DOI: 10.1016/j.eats.2019.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/21/2019] [Indexed: 02/03/2023] Open
Abstract
Medial patellofemoral ligament (MPFL) reconstruction is the treatment of choice for recurrent patellofemoral instability. Although attention to MPFL reconstruction in the orthopaedic literature has increased dramatically in recent years, there is no clear consensus on surgical technique, graft option, or method of fixation. Nevertheless, most studies have shown improved pain scores and low rates of recurrent dislocation in patients after surgery. Despite the early success of MPFL reconstruction, complications may occur more frequently than previously appreciated and include patellar fracture, postoperative instability, and loss of flexion. This article describes our technique for double-bundle MPFL reconstruction with an allograft while highlighting certain aspects of the procedure that are critical for achieving favorable outcomes. The main advantages of the technique include strong patellar fixation with suture anchors and anatomic graft placement at the origin and insertion of the native MPFL. In our experience, this method of reconstruction has been safe, reproducible, and effective in the treatment of patients with patellar instability.
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Affiliation(s)
- Alexander Rosinski
- Address correspondence to Alexander Rosinski, M.S., Advanced Orthopaedics and Sports Medicine, 450 Sutter St, Ste 400, San Francisco, CA 94108, U.S.A.
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Incidence of second-time lateral patellar dislocation is associated with anatomic factors, age and injury patterns of medial patellofemoral ligament in first-time lateral patellar dislocation: a prospective magnetic resonance imaging study with 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 2019; 27:197-205. [PMID: 30008056 DOI: 10.1007/s00167-018-5062-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/11/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To examine the predictors of the second-time lateral patellar dislocation (LPD) in patients after acute first-time LPD in a 5-year follow-up. METHODS Data were collected prospectively from patients after acute first-time LPD with conservative treatment. Factors included sex, age at the first-time LPD, anatomical variants [trochlear dysplasia, patellar height, tibial tuberosity-trochlear groove (TT-TG) distance], and injury patterns of medial patellofemoral ligament (MPFL) in acute first-time LPD. Logistic regression was carried out to identify the independent risk factors for the incidence of the second-time LPD. RESULTS The incidence rate of a second-time LPD was 35.5% (59 of 166) in the 5-year follow-up. Univariate analysis revealed significant differences in the incidence rate of the second-time LPD among age at the first-time LPD (P = 0.04), trochlear dysplasia (P = 0.003), patella height (P = 0.017) and the TT-TG distance (P = 0.027). Risk factors for the second-time LPD were age < 18 years at the first-time LPD [odds ratio (OR) 4.088], low-grade trochlear dysplasia (OR 7.214), high-grade trochlear dysplasia (OR 18.945), patella alta (OR 8.416), elevated TT-TG distance (OR 12.742), complete MPFL tear at its isolated femoral-side (OR 6.04) and complete combined MPFL tear (OR 5.851). CONCLUSIONS Trochlear dysplasia, elevated TT-TG distance, patella alta, age < 18 years at the first-time LPD, complete MPFL tear at its isolated femoral-side and complete combined MPFL tear in the first-time LPD are independently associated with a higher incidence rate of the second-time LPD. LEVEL OF EVIDENCE III.
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Arendt EA, Askenberger M, Agel J, Tompkins MA. Risk of Redislocation After Primary Patellar Dislocation: A Clinical Prediction Model Based on Magnetic Resonance Imaging Variables. Am J Sports Med 2018; 46:3385-3390. [PMID: 30398902 DOI: 10.1177/0363546518803936] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND First-time lateral patellar dislocations have historically been treated with a nonoperative approach; a clinical tool to predict patients who are most likely to redislocate may have clinical utility. PURPOSE (1) To determine if there are discriminating factors present between patients who redislocated their patellas and those who did not after a first-time lateral patellar dislocation and (2) to use this information to develop a model that can predict the recurrence risk of lateral patellar dislocation in this population. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS The study population included those with first-time lateral patellar dislocation, magnetic resonance imaging within 6 weeks, and 2-year minimum follow-up. Cohort A was from a prospective study with 2-year follow-up. Cohort B was a prospectively identified cohort with retrospective chart review. Follow-up was obtained clinically or via mail for patients without 2-year clinical follow-up. RESULTS Sixty-one patients (42%) out of 145 with primary lateral patellar dislocation had recurrent dislocation within 2 years. Stepwise logistic regression analysis demonstrated that skeletal immaturity (odds ratio, 4.05; 95% CI, 1.86-8.82; P = .0004), sulcus angle (odds ratio, 4.87; 95% CI, 2.01-11.80; P = .0005), and Insall-Salvati ratio (odds ratio, 3.0; 95% CI, 1.34-6.70; P = .0074) were significant predictors of redislocation. Receiver operator characteristic curves defined the cut points to be sulcus angle ≥154° and Insall-Salvati ratio ≥1.3. The probability of redislocation based on the presence of factors was 5.8% with no factors present and 22.7% with any 1 factor present, increasing to 78.5% if all 3 factors were present. CONCLUSION This model demonstrates a high risk of lateral patellar redislocation when a patient presents with skeletal immaturity as well as magnetic resonance measurements of sulcus angle ≥154° and patellar height as measured by Insall-Salvati ratio ≥1.3. A patient will have a low risk of lateral patellar redislocation with the inverse findings.
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Affiliation(s)
- Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Julie Agel
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- TRIA Orthopaedic Center, Bloomington, Minnesota, USA
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