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Pacheco-Garcia LM, Martín-Domínguez LA, Perelli S, Monllau JC, Simón-Sánchez FJ, Gutiérrez-de la O J, Messa LAM, Espregueira-Mendes J, Martínez-Guajardo KV, Morales-Avalos R. Combination of the medial patellofemoral ligament reconstruction with the quasi-anatomic technique, tibial tuberosity osteotomy, lateral retinaculum release and mosaicplasty produces satisfactory results for patients with patello-femoral instability. 2-Year follow-up. Knee 2024; 51:44-57. [PMID: 39236637 DOI: 10.1016/j.knee.2024.08.011] [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: 12/22/2023] [Revised: 06/21/2024] [Accepted: 08/09/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION This study aimed to evaluate the effectiveness and safety of a combined surgical approach for treating complex patellofemoral instability. This approach combines four procedures: medial patellofemoral ligament (MPFL) reconstruction with the quasi-anatomic technique, lateral retinaculum release, anteromedialization and distalization of tibial tuberosity and patellar/femoral mosaicplasty. MATERIAL AND METHODS Between August and November 2021, we enrolled 27 patients in the study (21 females, 6 males, average age 28.6 years). All with patella alta, recurrent patellar instability, severe cartilage focal damage, and increased tibial tubercle-trochlear groove distance. All underwent the combined procedure during this period. We assessed their pain and functional scores before surgery and at 6, 12, and 24 months after surgery using standardized scoring systems. RESULTS Patients initially reported significant pain and functional limitations. However, at 24 months, their pain scores significantly reduced, averaging 1.5 compared to 8.2 pre-surgery. Similarly, their functional scores substantially improved, with Lysholm, Tegner, Kujala, BPII scores reaching 87.44, 8.44, 90.03, 86.07 compared to 56.4, 3.7, 42.48, 23 pre-surgery, respectively. Importantly, no cases of recurrent instability occurred, and 96.3% of patients reported complete satisfaction. CONCLUSIONS This combined surgical approach has a high rate of success for patients with patella alta, recurrent lateral patellar instability, severe focal chondral lesions, and increased TT-TG distance. Moreover, 26 out of 27 patients (96.3%) reported total satisfaction. Therefore, we conclude that although this procedure combination is not simple, it is a safe, reproducible, and alleviates pain at 24 months postoperatively, and significantly improves functional scores.
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Affiliation(s)
- Luis Miguel Pacheco-Garcia
- Laboratory of Biomechanics, Articular Physiology and Experimental Orthopedic Surgery, Department of Physiology, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Lidia A Martín-Domínguez
- Departamento de Cirugia, Facultad de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; ICATKnee, ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Simone Perelli
- ICATKnee, ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Orthopedic Surgery and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Monllau
- ICATKnee, ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Orthopedic Surgery and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Jorge Gutiérrez-de la O
- Department of Traumatology, Medical Services of the Universidad Autónoma de Nuevo León, Monterrey, Mexico; Department of Human Anatomy, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - João Espregueira-Mendes
- FIFA Medical Centre of Excellence, Clínica do Dragão, Espregueira-Mendes Sports Centre, Porto, Portugal; School of Medicine, Minho University, Braga, Portugal
| | - Karla V Martínez-Guajardo
- Laboratory of Biomechanics, Articular Physiology and Experimental Orthopedic Surgery, Department of Physiology, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Rodolfo Morales-Avalos
- Laboratory of Biomechanics, Articular Physiology and Experimental Orthopedic Surgery, Department of Physiology, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico; Department of Traumatology, Medical Services of the Universidad Autónoma de Nuevo León, Monterrey, Mexico.
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Uppstrom TJ, Fletcher CF, Green DW, Gomoll AH, Strickland SM. Decreased Effective Patellar Tendon Length following Distalization Tibial Tubercle Osteotomy without Patellar Tendon Tenodesis. Orthop J Sports Med 2024; 12:23259671241227201. [PMID: 38371997 PMCID: PMC10870814 DOI: 10.1177/23259671241227201] [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: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 02/20/2024] Open
Abstract
Background Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. Purpose To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Study Design Case series; Level of evidence, 4. Methods Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. Results The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Conclusion Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.
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Affiliation(s)
- Tyler J. Uppstrom
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Connor F. Fletcher
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W. Green
- Department of Pediatric Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Andreas H. Gomoll
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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Li ZI, Garra S, Eskenazi J, Montgomery SR, Triana J, Hughes AJ, Alaia MJ, Strauss EJ, Jazrawi LM, Campbell KA. Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2024; 32:371-380. [PMID: 38270287 DOI: 10.1002/ksa.12051] [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: 11/29/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE To investigate the rate of return to sports and sport psychological readiness between patients who underwent isolated MPFLR (iMPFLR) compared to a matched cohort of patients who underwent MPFLR with anteromedializing tibial tubercle osteotomy (MPFLR/TTO). METHODS Patients who underwent primary MPFLR with or without TTO for recurrent patellar instability were retrospectively reviewed from 2012 to 2020 at a single institution. Preinjury sport and work information, Kujala, Tegner, Visual Analogue Score for pain, satisfaction and MPFL-Return to Sport after Injury (MPFL-RSI) score were collected. Two readers independently measured the tibial tuberosity-trochlear groove distance, Caton-Deschamps index and Dejour classification for trochlear dysplasia. Patients in iMPFLR and MPFLR/TTO groups were matched 1:1 on age, sex, body mass index and follow-up length. Multivariate regression analysis was performed to determine whether the MPFL-RSI was associated with a return to sport. RESULTS This study included 74 patients at mean follow-up of 52.5 months (range: 24-117). These groups returned to sport at similar rates (iMPFLR: 67.6%, MPFLR/TTO: 73.0%, not significant [ns]), though iMPFLR patients returned more quickly (8.4 vs. 12.8 months, p = 0.019). Rates of return to preinjury sport level were also similar (45.9% vs. 40.5%, ns). Patients with Dejour B/C took more time to return to sport compared to patients with mild/no trochlear pathology (13.8 vs. 7.9 months, p = 0.003). Increasing MPFL-RSI score was significantly predictive of the overall return to sport (odds ratio [OR]: 1.08, 95% confidence interval [CI] [1.03, 1.13], p < 0.001) and return to preinjury level (OR: 1.07, 95% CI [1.04, 1.13], p < 0.001). Most patients in iMPFLR and MPFLR/TTO groups resumed work (95.7% vs. 88.5%, ns), though iMPFLR patients who returned to preinjury work levels did so more quickly (1.7 vs. 4.6 months, p = 0.005). CONCLUSION Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. Patients with more severe trochlear pathology required more time to return to sports. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Sharif Garra
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
- Division of Orthopedic Surgery, Tel-Hashomer "Sheba" Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Jordan Eskenazi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Samuel R Montgomery
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Jairo Triana
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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Heindel K, Smoak J, Kocan J, Cossell C, Haider MN, Levy BJ, Bisson L. Stiffness and Instability After MPFL Reconstruction Using a Fluoroscopic Versus Open Technique to Localize the Femoral Attachment Site: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671221148482. [PMID: 37342554 PMCID: PMC10278418 DOI: 10.1177/23259671221148482] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 06/23/2023] Open
Abstract
Background Open and fluoroscopic techniques have been described for localization of the femoral attachment site in medial patellofemoral ligament (MPFL) reconstruction. No study to date has evaluated if one technique is superior to another in terms of complications. Purpose To review the literature comparing clinical outcomes of MPFL reconstruction using the fluoroscopic versus open technique to localize the site of femoral graft placement. Study Design Systematic review; Level of evidence, 4. Methods A systematic literature review was performed via PubMed, Embase, and CINAHL to identify articles published between the inception of these databases and March 1, 2022, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. This search yielded 4183 publications for initial review. Studies with at least a 2-year follow-up and complete reporting of patient-reported outcomes, range of motion, recurrent instability, and/or complications (ie, stiffness, infection, persistent pain) were included. We excluded studies of patients with collagen disorders; revision surgeries; surgeries with concomitant procedures; synthetic MPFL reconstruction; MPFL repairs; combined open and radiographic technique; and case series that included <10 patients. A proportional meta-analysis was performed by calculating the pooled estimate of incidence with 95% CIs using a fixed-effects model with double arcsine transformation (Freeman-Tukey) for each type of surgical technique (fluoroscopic or open). Results A total of 29 studies met our inclusion criteria, of which 15 studies (566 patients) used the open technique and 14 studies (620 patients) used fluoroscopy. There were no significant differences between the open and fluoroscopic techniques in the incidence of postoperative apprehension (P = .4826), postoperative subjective instability (P = .1095), postoperative objective instability (P = .5583), reoperations (P = .7981), recurrent dislocation (P = .6690), or arthrofibrosis (P = .8118). Conclusion Both open and radiographic localization of the femoral graft position in MPFL reconstruction offer similar outcomes and rates of complications.
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Affiliation(s)
- Koan Heindel
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Jason Smoak
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Joseph Kocan
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Charles Cossell
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Mohammad Nadir Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Benjamin J. Levy
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Leslie Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
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Pascual-Leone N, Chipman DE, Meza BC, Mintz DN, Fabricant PD, Green DW. Concomitant anterior medializing osteotomy and MPFL reconstruction improves patellar tilt when compared to MPFL reconstruction alone. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07396-x. [PMID: 37062043 DOI: 10.1007/s00167-023-07396-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/17/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Understanding how surgical procedures influence anatomic factors associated with patellofemoral instability can help guide surgeons when planning treatments for individual patients. This study sought to understand how patellar tilt is affected in adolescent patients with elevated pre-operative tibial tuberosity to trochlear groove (TT-TG) values undergoing medial patellofemoral ligament reconstruction (MPFLR) with or without an anterior medializing osteotomy (AMZ). METHODS Utilizing a prospective database of 274 patellofemoral instability patients who underwent MPFLR ± AMZ by one of two orthopedic surgeons at a single institution, those who underwent MPFLR + AMZ were identified. Pre-operative and post-operative magnetic resonance imaging (MRI) were used to measure TT-TG distance, while radiographs were used to measure patellar tilt (tilt). Patients were matched based on age at surgery (within 2 years) and pre-operative TT-TG distance (within 2 mm) to a comparison cohort of patients who underwent isolated MPFLR (iMPFLR) without osseous procedures. RESULTS A total of 56 patients were analyzed (28 per group). The mean age of the cohort was 15.5 ± 2.0 years and was similar between both groups (15.9 ± 1.9 versus 15.1 ± 2.0 years [n.s]). When comparing the two cohorts, significant pre- to post-operative decreases in patellar tilt for both MPFLR + AMZ (6.6 degrees, p < 0.001) and iMPFLR (3.9 degrees, p = 0.013) were noted. While there were no differences in pre-operative patellar tilt (21.2 ± 3.5 versus 21.1 ± 3.4 [n.s]), post-operatively, MPFLR + AMZ had significantly less patellar tilt than iMPFLR (13.2 ± 5.5 versus 16.5 ± 4.4, p = 0.017). CONCLUSIONS This study found that patellar tilt significantly improved in participants undergoing either MPFLR + AMZ or iMPFLR. In addition, those undergoing MPFLR + AMZ were found to have significantly lower post-operative tilt than those undergoing iMPFLR. If patellar tilt is found pre-operatively to be significantly elevated and a risk for future dislocations, these findings suggest that surgeons might strongly consider MPFLR with AMZ to further address the increased tilt. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicolas Pascual-Leone
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Danielle E Chipman
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Blake C Meza
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Douglas N Mintz
- Department of Radiology & Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Peter D Fabricant
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Daniel W Green
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.
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Kirby JC, Brenner ME, Jones H, Wilson PL, Ellis HB. Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort. Am J Sports Med 2023; 51:656-662. [PMID: 36722715 DOI: 10.1177/03635465221147516] [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] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population. PURPOSE The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements. RESULTS The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161). CONCLUSION MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.
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Affiliation(s)
- Julia C Kirby
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | - Hunter Jones
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
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