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Parikh SN, Schlechter JA, Veerkamp MW, Stacey JD, Gupta R, Pendleton AM, Shea KG, Friel NA, Molony JT, Yaniv M, Rhodes J, Finlayson CJ, Williams BA, Ellington M. Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents. J Pediatr Orthop 2024; 44:e369-e374. [PMID: 38258884 DOI: 10.1097/bpo.0000000000002616] [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: 01/24/2024]
Abstract
BACKGROUND The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.
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Affiliation(s)
- Shital N Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - John D Stacey
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rajul Gupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Nicole A Friel
- Shriners Hospitals for Children Northern California, Sacramento, CA
| | | | - Moshe Yaniv
- Dana Children's Hospital, Tel Aviv Medical Center, Israel
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Scanlon JP, Raymond AC, Aujla RS, Gohil S, Ebert JR, Lam LO, Malik SS, Simpson A, Otto JH, Neeson D, D'Alessandro P. Combined quadriceps medial patellofemoral ligament reconstruction and osteochondral fixation offers good patient-reported outcomes and low rates of recurrent instability for osteochondral defects secondary to acute patella dislocation. Knee Surg Sports Traumatol Arthrosc 2023; 31:4007-4015. [PMID: 37171605 DOI: 10.1007/s00167-023-07430-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE Chondral injuries secondary to traumatic patella dislocation are common, and a subgroup of these are significant defects with fragments amenable to fixation. There is a paucity of published evidence assessing patients managed with combined acute patellofemoral stabilisation and osteochondral fixation. The purpose of this study is to report the outcomes of patients with osteochondral injuries secondary to acute traumatic patella dislocation treated with combined early fragment fixation and MPFL reconstruction using a quadriceps tendon turndown technique which has distinct advantages for this cohort, including preventing chondral overloading and non-violation of the patella bone. METHODS Patients who underwent combined quadriceps tendon MPFL reconstruction and osteochondral fixation were included. Patient demographics, defect characteristics, complications and reoperations were evaluated. Patients were assessed with Lysholm, Kujala, KOOS-PF scores and satisfaction scale at follow up. Pre-operative MRI was assessed for presence of radiological risk factors for patella dislocation and post-operative MRI was used to assess cartilage quality with MOCART 2.0 score. RESULTS A total of 19 patients (63.2% female) were included. The mean age was 17.4 ± 4.8 years and patients were followed up at a mean 15.8 ± 5.1 months post-surgery. The mean defect size was 2.4 cm2 ± 1.3 cm2, with the most common defect location being the patella (13/19; 68.4%) followed by the lateral femoral condyle (5/19; 26.3%). At final follow up, the overall mean Lysholm, Kujala, and KOOS-PF scores were 84.9 ± 11.1, 89.7 ± 5.8 and 80.6 ± 13.6, respectively. Seventeen patients (89.5%) were satisfied with their outcome. The mean MOCART 2.0 score at final follow-up was 72.5. One patient required medial capsular plication with removal of a loose chondral body and microfracture and 3 knees required minor reoperations. CONCLUSION Combined acute osteochondral fragment fixation and MPFL reconstruction using a quadriceps tendon graft offers good radiological and patient-reported outcomes with high satisfaction and low rates of recurrent patella dislocation. To our knowledge, this is currently the largest series of its kind in the literature and the results of this study provide a rationale for a combined approach using a quadriceps tendon graft for this cohort. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- John P Scanlon
- Orthopaedic Research Foundation of Western Australia, Perth, Australia.
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia.
| | - Antony C Raymond
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Randeep S Aujla
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Satyen Gohil
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Jay R Ebert
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Australia
| | - Li-On Lam
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Shahbaz S Malik
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Ashley Simpson
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
| | - Jacobus H Otto
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Declan Neeson
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
- Medical School, Division of Surgery, University of Western Australia, Perth, Australia
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Courage O, van Rooij F, Saffarini M. Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:662-671. [PMID: 36114842 DOI: 10.1007/s00167-022-07154-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To synthesize the literature and critically appraise current evidence to determine the most accurate physical examination (clinical test or ultrasound) to detect pathologies of the long head of the biceps tendon (LHBT). METHODS A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of clinical tests or ultrasound versus arthroscopy for the assessment of LHBT pathologies were included. RESULTS Seven studies were included reporting on a total of 448 patients. One study on instability using ultrasound reported sensitivity and specificity of 1.00 and 0.96, respectively. Two studies on full-thickness tears using ultrasound reported sensitivity and specificity of 0.88-0.95 and 0.71-0.98, respectively. Four studies on partial-thickness LHBT tears reported sensitivity and specificity of 0.17-0.68 and 0.38-0.92, respectively, for clinical tests, versus 0.27-0.71 and 0.71-1.00, respectively, for ultrasound. Three studies on other LHBT pathologies reported sensitivity and specificity of 0.18-0.79 and 0.53-0.85, respectively, for clinical tests, versus 0.50 and 1.00, respectively, for ultrasound. CONCLUSION To detect LHBT pathologies, sensitivity is high-to-excellent using ultrasound, and moderate using Neer's sign and Speed's test, while specificity is high-to-excellent also using ultrasound, as well as the belly press, lift-off and Kibler's tests. The clinical relevance of these findings is that clinical tests are only reliable either to confirm or rule out LHBT pathologies, whereas ultrasound is reliable both to confirm and rule out LHBT pathologies. While diagnostic imaging cannot substitute for patient history and physical examination, the reliability and accessibility of ultrasound render it practical for routine use, particularly if clinical tests render unclear or contradictory findings. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Mo Saffarini
- ReSurg SA, Rue Saint Jean 22, 1260, Nyon, Switzerland
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D'Ambrosi R, Migliorini F, Cerciello S, Guerra G, Corona K, Mangiavini L, Ursino N, Vlaic J, Jelic M. Management of the first episode of traumatic patellar dislocation: an international survey. Knee Surg Sports Traumatol Arthrosc 2022; 31:2257-2265. [PMID: 36477349 DOI: 10.1007/s00167-022-07273-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This international survey aimed to evaluate the potential controversies regarding the management of first patellar dislocation amongst experienced knee surgeries in the treatment of the first episode of patellar dislocation without osteochondral fragments. METHODS An online survey was conducted from February 2021 to December 2021 to assess the global trend in the diagnosis and management of first-time patellar dislocation without osteochondral fragments. The online survey was accessible on the homepage of the website of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The questionnaire consisted of multiple-choice questions and was divided into three sections. The first section consisted of eight questions regarding demographic information, professional activity, and responder experience. The second section consisted of 13 questions regarding the approach to a first patellar dislocation (clinical examination, imaging, and rehabilitation). The third section contained 2 questions concerning the relevance of patient characteristics to the therapeutic algorithm (age, sports, and pathoanatomical predisposing risk factors). RESULTS A total of 438 orthopaedic surgeons worldwide completed the questionnaire. At the first approach to diagnose a first-time patellar dislocation, 251 (57%) of the surgeons requested plain radiographs, and 158 (36%) requested magnetic resonance imaging (MRI). In conservatively treated patients, 368 (84%) of the respondents recommended the use of a knee brace. Amongst them, 14 (3%) advocated its use for one week, 75 (17%) for two weeks, 123 (28%) for three weeks, 105 (24%) for four weeks, and 97 (22%) for six weeks. In conservatively treated patients, 215 (49%) of the surgeons recommended load to tolerance, 148 (34%) recommended 30% to 60% of the bodyweight, and 75 (17%) advised against weight-bearing. More than half of the surgeons considered a patient aged less than 35 years practising contact sports to be a candidate for the medial patello-femoral ligament (MPFL) procedure. In addition, a tibial tuberosity to trochlear groove distance (TT-TG) distance of 15 to > 20 mm (for > 75% of the surgeons) and a trochlea types C and D (for > 70% of the surgeons) were considered possible indications for direct surgical management. CONCLUSION At the first approach to diagnose a first-time patellar dislocation, plain radiographs and MRI should be performed. In conservatively treated patients, most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with range of motion of full extension to 30° during the first 15 days and up to 60° for an additional 15 days. Surgical management should be performed in patients in the second and third decades of life practising contact sports and in those patients who present types C and D trochlea dysplasia and patella alta. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy. .,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
| | - Simone Cerciello
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy.,Casa di Cura Villa Betania, Rome, Italy.,Marrelli Hospital, Crotone, Italy
| | - Germano Guerra
- Department of Medicine, Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
| | - Katia Corona
- Department of Medicine, Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
| | - Laura Mangiavini
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | | | - Mislav Jelic
- Department of Orthopaedic Surgery, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
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