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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] [Key Words] [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 includes 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, MA, USA
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Fan W, Dang S, Tan X, Liu J, Yang YK, Xiang FF. Computational evaluation of wire position using separate vertical wire technique and candy box technique for the fixation of inferior pole patellar fractures: a finite element analysis. Front Bioeng Biotechnol 2024; 12:1353901. [PMID: 38720880 PMCID: PMC11076871 DOI: 10.3389/fbioe.2024.1353901] [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] [Received: 12/11/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024] Open
Abstract
The separate vertical wire (SVW) technique and the improved candy box (CB) technique have been proposed for treating inferior pole patellar fractures. However, there is still a lack of clear explanation regarding the location of the wire passing through the patella. Five models of SVW techniques were established in different positions. Finite element analysis was then conducted to determine the optimal bone tunnel position for the SVW technique. Based on these findings, six groups of finite element models were created for CB techniques. The maximum displacement and stress on both the patella and steel wire were compared among these groups under 100-N, 200-N, 300-N, 400-N, and 500-N force loads. The results indicated that, in the SVW technique, the steel wire group near the fracture end of the longitudinal bone tunnel showed minimal displacement and stress on the patella when subjected to different forces. On the other hand, in the CB technique, both the patella and wire experienced minimal stress when a transverse bone tunnel wire was placed near the upper posterior aspect of patella. In conclusion, the SVW technique may require the bone tunnel wire to be positioned near the fractured end of the lower pole of the patella. On the other hand, in CB technique, the transverse bone tunnel wire passing through the patella may be close to its upper posterior aspect. However, further validation is necessary through comprehensive finite element analysis and additional biomechanical experiments.
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Affiliation(s)
- Wei Fan
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Shunjie Dang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Xiaoqi Tan
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinhui Liu
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Yun-Kang Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Fei-Fan Xiang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
- State Key Laboratory of Quality Research in Chinese Medicine, Macau University of Science and Technology, Macau, China
- Department of Nuclear Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Monaco E, Criseo N, Annibaldi A, Carrozzo A, Pagnotta SM, Cantagalli MR, Orlandi P, Daggett M. Medial Patellofemoral Ligament Reconstruction Using Gracilis Tendon Graft and "All Suture" Knotless Anchors for Patellar Fixation. Arthrosc Tech 2023; 12:e2329-e2334. [PMID: 38196870 PMCID: PMC10773230 DOI: 10.1016/j.eats.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 01/11/2024] Open
Abstract
Patellar dislocation is a frequent sports-related knee injury. The primary restraint to lateral translation of patella is medial patellofemoral ligament. Several treatments for patella dislocation have been described in the literature. The purpose of this Technical Note is to describe the surgical technique for medial patellofemoral ligament reconstruction using gracilis tendon and 2 knotless soft anchors, avoiding patella tunneling.
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Affiliation(s)
- Edoardo Monaco
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Natale Criseo
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Alessandro Annibaldi
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Alessandro Carrozzo
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Susanna M Pagnotta
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | | | - Pierfrancesco Orlandi
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
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Neumann-Langen MV, Sontheimer V, Näscher J, Izadpanah K, Schmal H, Kubosch EJ. Incidence of postoperative complications in patellar fractures related to different methods of osteosynthesis procedures - a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:871. [PMID: 37946171 PMCID: PMC10634146 DOI: 10.1186/s12891-023-06998-3] [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: 05/29/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Patellar fractures have a comparatively low incidence compared to all fracture frequencies of the musculoskeletal system. However, surgical management is crucial to prevent postoperative complications that affect the knee joint. The purpose of the present study was to evaluate the incidence of postoperative complications and onset of postoperative osteoarthritis related to the chosen technique of patellar fracture management. METHODS In a retrospective cohort study consecutive managed, isolated patella fractures were reviewed for demographic data, trauma mechanism, patella fracture type, fixation technique and postoperative complications. The results were documented radiographically and clinically and analysed statistically. The reporting followed the STROBE guidelines. RESULTS A total of 112 patients were eligible for data evaluation. Surgical management of comminuted patellar fractures with small fragment screws showed significant fewer postoperative complications compared to other fixation techniques (8%, p < 0.043). The incidence of posttraumatic infection was significantly higher following the hybrid fixation technique with cannulated screws and tension wire than following the other analysed techniques (p = 0.024). No postoperative wound infection was observed after screw fixation or locking plate fixation. Symptomatic hardware was most frequently seen after tension-band fixation. Onset of posttraumatic osteoarthritis was most often found after the hybrid fixation technique (55%). CONCLUSION Surgical management of patellar fractures remains crucial but fracture fixation using plating systems or small fragment screws is least associated with postoperative complications. TRIAL REGISTRATION Trial registration number (DRKS):00027894.
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Affiliation(s)
- M V Neumann-Langen
- Department of Orthopaedic and Trauma Surgery, Klinikum Konstanz, Mainaustrasse 35, 78464, Konstanz, Germany.
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - V Sontheimer
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - J Näscher
- Department of Mathematics and Statistics, University of Konstanz, Eggerthaldestrasse D, 78457, Konstanz, Germany
| | - K Izadpanah
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - H Schmal
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
- Department of Orthopedic Surgery, University Hospital Odense, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - E J Kubosch
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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McKay RM, Duffy DJ, Chang YJ, Beamon W, Moore GE. Biomechanical evaluation of three adjunctive methods of orthopedic tension band-wire fixation to augment simulated patella tendon repairs in dogs. Vet Surg 2023; 52:1140-1149. [PMID: 37534913 DOI: 10.1111/vsu.14000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To evaluate the effects of three adjunctive methods of tension band wire fixation (TBWF) on the biomechanical properties, gap formation, and failure mode in simulated canine patella tendon rupture (RPT). STUDY DESIGN Randomized, ex vivo. SAMPLE POPULATION Paired hindlimbs from 32 dog cadavers. METHODS Patellar tendons (PTs) and associated bone-muscle-tendon units were harvested. Each PT was transected then sutured using a core locking loop and simple continuous epitendinous pattern. Each hindlimb was randomly assigned to one of three groups (n = 18 hindlimbs/group) using 18 gauge 316 L wire, anchored to the tibial crest distally, to perform transpatellar, suprapatellar, or combined tension band-wire (TBW) augmentation. Ten hindlimbs were utilized as control specimens. Yield, peak, and failure loads, stiffness, loads to 1 and 3 mm gap formation, and failure mode were evaluated. RESULTS Combined transpatellar and suprapatellar TBW augmentation was superior to transpatellar or suprapatellar groups alone. Yield (p = .0008), peak (p = .004), and failure loads (p = .005) were greater for the combined group than for the transpatellar (p = .048) and suprapatellar groups (p = .01) respectively. There was no difference regarding the occurrence of 1 or 3 mm gap formation (1 mm, p = .05; 3 mm, p = .06); however, loads required to cause gap formation were greater in the combined group (p = .036). Mode of failure differed between techniques used for PT augmentation (p < .001). CONCLUSION Combined transpatellar and suprapatellar adjunctive TBW augmentation for simulated PT repairs was biomechanically superior to either transpatellar or suprapatellar TBWF alone. CLINICAL SIGNIFICANCE Combined suprapatellar and transpatellar TBWF may offer a viable surgical option for increased repair-site strength and greater loads to gap formation. Further studies investigating alternative techniques and materials for RPT repair augmentation are warranted.
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Affiliation(s)
- Rachel M McKay
- Department of Clinical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Daniel J Duffy
- Department of Clinical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Yi-Jen Chang
- Department of Clinical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Weston Beamon
- Department of Clinical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - George E Moore
- Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
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Fan W, Liu J, Tan X, Wei D, Yang Y, Xiang F. Candy box technique for the fixation of inferior pole patellar fractures: finite element analysis and biomechanical experiments. BMC Musculoskelet Disord 2023; 24:835. [PMID: 37872511 PMCID: PMC10594795 DOI: 10.1186/s12891-023-06946-1] [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: 08/01/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Maintaining effective reduction and firm fixation in inferior pole patellar fractures is a highly challenging task. There are various treatment methods available; although tension-band wiring combined with cerclage wiring (TBWC) is the mainstream approach, its effectiveness is limited. Herein, we propose and evaluate a new technique called candy box (CB), based on separate vertical wiring (SVW), for the treatment of inferior pole patellar fractures. Specifically, we provide biomechanical evidence for its clinical application. METHODS Five fixation models were built: SVW combined with cerclage wiring (SVWC); TBWC; modified SVW with the middle (MSVW-A) or upper (MSVW-B) 1/3 of the steel wire reserved, and CB. A finite element analysis was performed to compare the displacement and stress under 100-N, 200-N, 300-N, 400-N and 500-N force loads. Three-dimensional printing technology was utilized to create fracture models, and the average displacement of each model group was compared under a 500-N force. RESULTS The results of the finite element analysis indicate that CB technology exhibits significantly lower maximum displacement, bone stress, and wire stress compared to that with other technologies under different loads. Additionally, in biomechanical experiments, the average force displacement in the CB group was significantly smaller than that with other methods under a 500-N force (P < 0.05). CONCLUSIONS CB technology has the potential to overcome the limitations of current techniques due to its superior biomechanical characteristics. By incorporating early functional exercise and ensuring strong internal fixation, patient prognosis could be enhanced. However, further clinical trials are needed to fully evaluate the therapeutic effects of CB technology.
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Affiliation(s)
- Wei Fan
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Jinhui Liu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Xiaoqi Tan
- Department of Dermatology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Daiqing Wei
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China
| | - Yunkang Yang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China.
| | - Feifan Xiang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, China.
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Barber FA. Editorial Commentary: Quadriceps Tendon Suture Anchor Repair Provides Better Patient-Reported Outcomes Than Transosseous Tunnel Repair: Defining the New Gold Standard. Arthroscopy 2023; 39:1490-1492. [PMID: 37147076 DOI: 10.1016/j.arthro.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/07/2023] [Indexed: 05/07/2023]
Abstract
Quadriceps tendon suture anchor repair provides biomechanically greater and more consistent failure loads than transosseous tunnel repair, including less cyclic displacement (gap formation). Although satisfactory clinical outcomes are found with both repair techniques, few studies provide a side-to-side comparison. However, recent research demonstrates better clinical outcomes in using suture anchors, with equal failure rates. Suture anchor repair is minimally invasive requiring smaller incisions, less patellar dissection, and eliminates patellar tunnel drilling that can breach the anterior cortex, create stress risers, result in osteolysis from nonabsorbable intraosseous sutures and longitudinal patellar fractures. Suture anchor quadriceps tendon repair should now be considered the gold standard.
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Medial Patellofemoral Ligament Reconstruction: A Surgical Technique to Dynamically Control Graft Tension. Arthrosc Tech 2022; 11:e2309-e2318. [PMID: 36632405 PMCID: PMC9827002 DOI: 10.1016/j.eats.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/22/2022] [Indexed: 11/19/2022] Open
Abstract
The medial patellofemoral ligament is an important patellar stabilizer and, when damaged, can lead to recurrent instability, cartilage injury, and debilitating pain among other conditions. In patients with continued patellar instability after failed nonoperative management, medial patellofemoral ligament reconstruction often is recommended. A key step of the procedure is appropriate graft tensioning. Previously described techniques can help guide the surgeon, but few allow for adjustable tensioning after dynamic examination of patellar tracking to avoid over tensioning. This technique offers the ability to dynamically control graft tension with 2 independent graft limbs while also using knotless onlay type fixation, therefore decreasing the risk of over- or undertensioning and the complications that come with it.
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Qiao Y, Xu J, Ye Z, Chen J, Zhang X, Zhao S, Xu C, Zhao J. Double-Tunnel Technique Was Similar to Single-Tunnel Technique in Clinical, Imaging and Functional Outcomes for Medial Patellofemoral Ligament Reconstruction: A Randomized Clinical Trial. Arthroscopy 2022; 38:3058-3067. [PMID: 35690254 DOI: 10.1016/j.arthro.2022.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to compare the clinical, functional, and imaging outcomes of single-tunnel (ST) and double-tunnel (DT) techniques for medial patellofemoral ligament (MPFL) reconstruction. METHODS Ninety-four patients with recurrent patellar instability were randomly divided into 2 groups, receiving either ST or DT MPFL reconstruction. Lateral reticulum release (LRR) and tibial tuberosity (TT) transfer were performed as combined procedures when necessary. Preoperative and postoperative clinical characteristics (symptoms and episodes of redislocation), functional outcomes (Kujala, Lysholm, Tegner, IKDC, and KOOS score), and radiological measurements (congruence angle, patellar tilt angle, lateral patellar angle, and lateral patellar translation) were analyzed. RESULTS The analysis included data from 90 patients with 48 patients in the ST group and 42 patients in the DT group. Patients were followed up for a mean period of 37.8 (range: 27-50) months in the ST group and 38.6 (range: 25-53) months in the DT group. Forty-three patients in the ST group and 40 patients in the DT group received combined TT transfer, and all patients underwent LRR. At the latest follow-up, 1 patient in ST group experienced redislocation, while no patient in the DT group sustained clinical failure (P = .347). Imaging measurements decreased significantly to the normal range postoperatively. No significant difference was noted between the postoperative radiological results of the 2 groups. All clinical scores significantly improved postoperatively, and no significant difference was observed between the 2 groups except for the higher Lysholm score (P = .031), KOOS symptoms score (P = .021) and KOOS knee-related quality of life score (P = .043) in the DT group. CONCLUSION Both techniques could equally mitigate the patellar lateral translation or redislocation. Our results demonstrate several significant differences in functional outcomes that favored DT MPFL reconstruction but no difference in clinical failure rates and radiological results between ST and DT MPFL reconstruction. LEVEL OF EVIDENCE Level I, randomized clinical trial.
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Affiliation(s)
- Yi Qiao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiuyuan Zhang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Song Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Wierer G, Winkler PW, Pomwenger W, Plachel F, Moroder P, Seitlinger G. Transpatellar bone tunnels perforating the lateral or anterior cortex increase the risk of patellar fracture in MPFL reconstruction: a finite element analysis and survey of the International Patellofemoral Study Group. Knee Surg Sports Traumatol Arthrosc 2022; 30:1620-1628. [PMID: 34333671 DOI: 10.1007/s00167-021-06682-w] [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: 02/23/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE (1) To determine applied patellar drilling techniques for medial patellofemoral ligament (MPFL) reconstruction among members of the International Patellofemoral Study Group (IPSG) and (2) to evaluate the risk of patellar fracture for various patellar bone tunnel locations based on a finite element analysis (FEA) model. METHODS In the first part of the study, an online survey on current MPFL reconstruction techniques was conducted among members of the IPSG. In the second part of the study, a three-dimensional FEA model of a healthy knee joint was created using a computed tomography scan. Patient-specific bone density was integrated into the patella, and cartilage of 3 mm thickness was modeled for the patellofemoral joint. According to the survey's results, two different types of patellar bone tunnels (bone socket and transpatellar bone tunnel) were simulated. The risk of patellar fracture was evaluated based on the fracture risk volume (FRV) obtained from the FEA. RESULTS Finite element analysis revealed that subchondral bone socket tunnel placement is associated with the lowest FRV but increased with an anterior offset (1-5 mm). Transpatellar bone tunnels violating the lateral or anterior cortex showed a higher FRV compared to bone socket, with the highest values observed when the anterior cortex was penetrated. CONCLUSION Violation of the anterior or lateral patellar cortex using transpatellar bone tunnels increased FRV compared to a subchondral patellar bone socket tunnel. In MPFL reconstruction, subchondral patellar bone socket tunnels should be considered for patellar graft fixation to avoid the risk of postoperative patellar fracture. LEVEL OF EVIDENCE Survey; Descriptive laboratory study/Level V.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria. .,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT, Eduard-Wallnöfer-Zentrum 1, 6060, Hall in Tirol, Austria.
| | - Philipp W Winkler
- Department for Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Werner Pomwenger
- Department of Information Technology & Systems, Salzburg University of Applied Sciences, Urstein Süd 1, 5412, Puch bei Salzburg, Austria
| | - Fabian Plachel
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.,Center for Musculoskeletal Surgery, Charité -Universitatsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Charité -Universitatsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Gerd Seitlinger
- Orthofocus, Guggenbichlerstrasse 20, 5026, Salzburg, Austria
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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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O'Donnell R, Lemme NJ, Marcaccio S, Walsh DF, Shah KN, Owens BD, DeFroda SF. Suture Anchor Versus Transosseous Tunnel Repair for Inferior Pole Patellar Fractures Treated With Partial Patellectomy and Tendon Advancement: A Biomechanical Study. Orthop J Sports Med 2021; 9:23259671211022245. [PMID: 34423057 PMCID: PMC8371734 DOI: 10.1177/23259671211022245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/23/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Comminuted inferior pole patellar fractures can be treated in numerous ways.
To date, there have been no studies comparing the biomechanical properties
of transosseous tunnels versus suture anchor fixation for partial
patellectomy and tendon advancement of inferior pole patellar fractures. Hypothesis: Suture anchor repair will result in less gapping at the repair site. We also
hypothesize no difference in load to failure between the groups. Study Design: Controlled laboratory study. Methods: Ten cadaveric knee extensor mechanisms (5 matched pairs; patella and patellar
tendon) were used to simulate a fracture of the extra-articular distal pole
of the patella. The distal simulated fracture fragment was excised, and the
patellar tendon was advanced and repaired with either transosseous bone
tunnels through the patella or 2 single-loaded suture anchors preloaded with
1 suture per anchor. Load to failure and elongation from cycles 1 to 250
between 20 and 100 N of force were measured, and modes of failure were
recorded. Statistical analysis was performed using a paired 2-tailed Student
t test. Results: The suture anchor group had less gapping during cyclic loading as compared
with the transosseous tunnel group (mean ± SD, 6.83 ± 2.23 vs 13.30 ± 5.74
mm; P = .047). There was no statistical difference in the
load to failure between the groups. The most common mode of failure was at
the suture-anchor interface in the suture anchor group (4 of 5) and at the
knot proximally on the patella in the transosseous tunnel group (4 of
5). Conclusion: Suture anchors yielded similar strength profiles and less tendon gapping with
cyclic loading when compared with transosseous tunnels in the treatment of
comminuted distal pole of the patellar fractures managed with partial
patellectomy and patellar tendon advancement. Clinical Relevance: Suture anchors may offer robust repair and earlier range of motion in the
treatment of fractures of the distal pole of the patella. Clinical
randomized controlled trials would help clinicians better understand the
difference in repair techniques and confirm the translational efficacy in
clinical practice.
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Affiliation(s)
- Ryan O'Donnell
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Stephen Marcaccio
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Devin F Walsh
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Kalpit N Shah
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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Single-Incision, Single Patellar Tunnel For Double-Bundle Medial Patellofemoral Ligament Reconstruction: A Technical Note. Arthrosc Tech 2021; 10:e2107-e2112. [PMID: 34504749 PMCID: PMC8417225 DOI: 10.1016/j.eats.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/17/2021] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament (MPFL) is the main medial stabilizer of the patella, while reconstruction of the ligament is a common surgery performed by orthopedic surgeons. Although several surgical methods have been described regarding MPFL reconstruction, the common goals of these surgeries are to imitate the anatomic features of the native MPFL. In the single-incision and single patellar tunnel and double-bundle MPFL reconstruction technique, we will present the anatomical footprint of the MPFL located in the medial aspect of the patella, which is filled with the graft. In this technique, graft fixation is performed in the femoral tunnel using only one bioabsorbable screw without the need for fixation in the patella.
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Dalla-Rosa J, Nogales JJ, Verdejo M, Nogales JI. Medial Patellofemoral Ligament Reconstruction: Use of All-Suture Anchors for Patellar Fixation and a Dynamic Femoral Attachment. Arthrosc Tech 2021; 10:e1345-e1350. [PMID: 34141552 PMCID: PMC8185889 DOI: 10.1016/j.eats.2021.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament is one of the most relevant structures preventing patellar dislocation. Numerous surgical techniques have been described to reconstruct this structure and patellar biomechanics. Complications after this procedure concern both patella and femur. This technique avoids tunneling the patella and the use of intraoperative radiographs by using the adductor magnus tendon insertion.
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Affiliation(s)
- Jaime Dalla-Rosa
- Complejo Hospitalario Integral Privado, Málaga, Spain
- Address correspondence to Jaime Dalla-Rosa, M.Sc., Avenida de Carlos Haya 121, 29010, Málaga, Spain.
| | | | | | - José I. Nogales
- Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
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15
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Moreira FP, Costa FP, Santos SA, Oliveira PR. Superior pole patellar sleeve fracture after medial patellofemoral ligament reconstruction. BMJ Case Rep 2021; 14:14/1/e239364. [PMID: 33495191 PMCID: PMC7839895 DOI: 10.1136/bcr-2020-239364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A 13-year-old boy sustained a superior pole patellar sleeve fracture after a blunt trauma of the knee. A medial patellofemoral ligament reconstruction had been performed 4 weeks earlier. The patient underwent surgery to reinsert the quadriceps tendon in the superior pole of the patella using two bone suture anchors. One-year postoperative assessment revealed excellent functional outcomes. Sleeve fractures are easily misdiagnosed, and in our case, clinical examination was essential in order to perform the diagnosis.
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Bulaïd Y, Fabre M, Parratte S, Argenson JN, Ollivier M. Patella Distal Pole Fracture Treated Using Ipsilateral Hamstring Autograft Augmentation and No Additional Hardware. Arthrosc Tech 2020; 10:e61-e65. [PMID: 33532209 PMCID: PMC7823080 DOI: 10.1016/j.eats.2020.09.013] [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: 04/23/2020] [Accepted: 09/11/2020] [Indexed: 02/03/2023] Open
Abstract
Patellar lower-pole fractures occur in relatively young patients after eccentric contraction of the quadriceps or direct trauma. Early diagnosis and adequate treatment lead to excellent outcomes and prevent tendon retraction and scarring. The aim of surgical treatment is to restore articular congruence and reestablish the extensor mechanism of the knee. All surgical treatments (sutures and tension band wiring, separate vertical wiring or augmented with Krackow sutures, wiring through screws, basket plate, hook plate) use additional hardware. We propose a hardware-free technique using ipsilateral hamstring augmentation.
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Affiliation(s)
- Yassine Bulaïd
- Caportho, Centre de Chirurgie Orthopédique et Sportive, Béthune, France,Clinique Anne d’Artois, Béthune, France,Address correspondence to Yassine Bulaïd, MD, Caportho, Centre de Chirurgie Orthopédique et Sportive, Clinique Anne d’Artois, 100 Rue Emile Basly, 62400 Béthune, France.
| | - Maxime Fabre
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Sébastien Parratte
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Jean-Noël Argenson
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Matthieu Ollivier
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
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Fehske K, Berninger MT, Alm L, Hoffmann R, Zellner J, Kösters C, Barzen S, Raschke MJ, Izadpanah K, Herbst E, Domnick C, Schüttrumpf JP, Krause M. [Current treatment standard for patella fractures in Germany]. Unfallchirurg 2020; 124:832-838. [PMID: 33331976 PMCID: PMC8460507 DOI: 10.1007/s00113-020-00939-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The treatment of patella fractures is technically demanding. Although the radiological results are mostly satisfactory, this often does not correspond to the subjective assessment of the patients. The classical treatment with tension band wiring with K‑wires has several complications. Fixed-angle plate osteosynthesis seems to be biomechanically advantageous. OBJECTIVE Who is treating patella fractures in Germany? What is the current standard of treatment? Have modern forms of osteosynthesis become established? What are the most important complications? MATERIAL AND METHODS The members of the German Society for Orthopedics and Trauma Surgery and the German Knee Society were asked to participate in an online survey. RESULTS A total of 511 completed questionnaires were evaluated. Most of the respondents are specialized in trauma surgery (51.5%), have many years of professional experience and work in trauma centers. Of the surgeons 50% treat ≤5 patella fractures annually. In almost 40% of the cases preoperative imaging is supplemented by computed tomography. The classical tension band wiring with K‑wires is still the preferred form of osteosynthesis for all types of fractures (transverse fractures 52%, comminuted fractures 40%). In the case of comminuted fractures 30% of the surgeons choose fixed-angle plate osteosynthesis. If the inferior pole is involved a McLaughlin cerclage is used for additional protection in 60% of the cases. DISCUSSION The standard of care for patella fractures in Germany largely corresponds to the updated S2e guidelines. Tension band wiring is still the treatment of choice. Further (long-term) clinical studies are needed to verify the advantages of fixed-angle plates.
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Affiliation(s)
- Kai Fehske
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische- und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
| | - Markus T Berninger
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Lena Alm
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Unfallkrankenhaus Hamburg, Hamburg, Deutschland
| | | | - Johannes Zellner
- Klinik für Unfallchirurgie, Caritas-Krankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Clemens Kösters
- Klinik für Orthopädie, Unfall- und Handchirurgie, Maria-Josef-Hospital Greven, Greven, Deutschland
| | - Stefan Barzen
- BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Kaywan Izadpanah
- Klinik für Orthopädie und Unfallchirurgie, Department für Chirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Elmar Herbst
- Klinik für Unfall‑, Hand und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | | | | | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Comparison of the Therapeutic Effects of Tension Band with Cannulated Screw and Tension Band with Kirschner Wire on Patella Fracture. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2020; 2020:4065978. [PMID: 32908578 PMCID: PMC7468626 DOI: 10.1155/2020/4065978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 11/17/2022]
Abstract
Background Patella fracture accounts for 1% of bone injury, of which anatomical reduction is of great significance to the recovery. Tension band with cannulated screw and Kirschner wire is commonly used methods for the treatment of displaced patella fracture. However, there is still some controversy on the clinical efficacy of the two treatment methods. Objective This study aimed at comparing the therapeutic effects of the cannulated screw and Kirschner wire tension bands on patella fracture and at providing more data basis for clinical selection of treatment methods for patella fracture. Methods Altogether, 146 patients with displaced patella fracture admitted to our hospital from March 2016 to February 2018 were selected and divided into two groups according to the different treatment methods. Among them, 71 patients received tension band with a cannulated screw (TBWCS group) and 75 patients received tension band with Kirschner wire (TBWKW group). Two groups of patients were compared in terms of surgical treatment effect after one year of treatment, complications within six months after the operation and operation-related indexes. The pain visual analogue scale (VAS) score, knee flexion degree, Lysholm score, and Bostman score were recorded at 1, 3, 6, and 12 months after operation, and the activity of daily living scale (ADL) score was evaluated at the last follow-up. Results During the operation of patella fracture patients, the intraoperative blood loss, hospitalization time, and knee flexion loss of patients in TBWCS group were less than those in the TBWKW group (P < 0.05), the starting time of postoperative functional exercise was earlier than that of patients in TBWKW group (P < 0.05), and the incidence rate of secondary operation was lower than that of patients in the TBWKW group (P < 0.05), but there was no statistical difference in the operation time, incision length, and postoperative fracture gap between the two groups. The results of curative effect analysis showed that the knee flexion, Lysholm score, and Bostman score of patients treated with tension band with cannulated screw were higher than those treated with Kirschner wire (P < 0.05), and VAS score was lower. Tension band with cannulated screw had a better curative effect on patella fracture (P < 0.05), lower complication rate (P < 0.05), and higher quality of life of patients (P < 0.05). Conclusion Tension band with cannulated screw has a good curative effect on patella fracture, low incidence of complications, early start of postoperative functional exercise, and high quality of life.
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19
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Medial patellofemoral ligament reconstruction using a central strip of the quadriceps tendon in patients with recurrent patellar instability: a prospective case series. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Zhang H, Ye M, Liang Q. Clinical Outcomes After Medial Patellofemoral Ligament Reconstruction With Suture Fixation of the Gracilis Tendon via Transosseous Tunnels. Orthop J Sports Med 2020; 8:2325967119900373. [PMID: 32095487 PMCID: PMC7011329 DOI: 10.1177/2325967119900373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/10/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Several fixation methods have been introduced in medial patellofemoral ligament (MPFL)
reconstruction. However, the optimal management of patients with recurrent patellar
dislocation remains controversial. Purpose: To present a case series with a minimum 2-year follow-up of 29 patients with recurrent
patellar dislocation who underwent a new transosseous suture fixation technique for MPFL
reconstruction. Study Design: Case series; Level of evidence, 4. Methods: From January 2014 through February 2016, a total of 29 patients with recurrent patellar
dislocation for which the MPFL was reconstructed with transosseous suture patellar
fixation were studied. All patients were available for follow-up (mean, 37.52 months;
range, 26-48 months). The patellar attachment was fixed by transosseous patellar
sutures. The International Knee Documentation Committee (IKDC) subjective knee score,
Kujala score, Tegner score, range of motion, congruence angle, patellar tilt angle, and
complications were assessed both pre- and postoperatively. Results: No recurrent dislocation was observed in any of the 29 patients for a minimum of 2
years. All outcome scores improved significantly from preoperatively to postoperatively:
the average IKDC subjective knee evaluation score from 53 to 87, Kujala from 54 to 90,
Lysholm from 50 to 89, and Tegner from 3 to 5 (P < .001 for all).
The congruence angle significantly decreased from 22° preoperatively to –3°
postoperatively, and the patellar tilt angle (Merchant) decreased from 23°
preoperatively to 5° postoperatively (P < .001 for both). In total,
25 patients (25/29; 86.21%) were completely pain-free when performing activities of
daily living at the last follow-up, and 27 patients (93.1%) rated themselves as very
satisfied or satisfied with the results. Conclusion: In patients with chronic recurrent patellar dislocation, transosseous patellar suture
fixation for MPFL reconstruction can significantly improve patellar stability and
achieve good results at short-term follow-up.
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Affiliation(s)
- Hangzhou Zhang
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Mao Ye
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qingwei Liang
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
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Lösungen für häufige Komplikationen bei Patella-Stabilisierungseingriffen. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Editorial Commentary: Socket or Knock It? Considerations in Patellar Fixation During Medial Patellofemoral Ligament Reconstruction. Arthroscopy 2019; 35:1629-1630. [PMID: 31054735 DOI: 10.1016/j.arthro.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 02/02/2023]
Abstract
The medial patellofemoral ligament (MPFL) is the primary static stabilizer to lateral patellar translation, and reconstruction of this ligament has been shown to be successful in reducing dislocation rates and improving functional outcomes in the treatment of patellar instability. Recent studies have warned that complication rates after MPFL reconstruction can be as high as 25%, with patellar fracture being one of the most catastrophic complications that can occur after this procedure. While the use of a bone socket versus cortical fixation on the patella does not appear to influence outcomes, surgeons should take into account the factors of graft and tunnel positioning, graft length/tension, and the need for concurrent procedures in each individual patient when performing this procedure. Any violation of the patella, whether as a socket or for anchor placement, should avoid the anterior cortex and maintain an adequate bony bridge that should be modified according to the patient's anatomy. The optimal technique for MPFL reconstruction continues to evolve, and further studies are needed to identify the ideal type and position of patellar fixation to minimize risks of complications and optimize surgical outcomes when performing MPFL reconstruction in the treatment of patellar instability.
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Desai VS, Tagliero AJ, Parkes CW, Camp CL, Cummings NM, Stuart MJ, Dahm DL, Krych AJ. Systematic Review of Medial Patellofemoral Ligament Reconstruction Techniques: Comparison of Patellar Bone Socket and Cortical Surface Fixation Techniques. Arthroscopy 2019; 35:1618-1628. [PMID: 31000392 DOI: 10.1016/j.arthro.2018.10.150] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient-reported outcomes. METHODS A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow-up were excluded. Risk-of-bias assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient-reported outcomes were collected. RESULTS A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. CONCLUSIONS MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Vishal S Desai
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Chad W Parkes
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nancy M Cummings
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Diane L Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A..
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No Difference in Outcome Between Femoral Soft-Tissue and Screw Graft Fixation for Reconstruction of the Medial Patellofemoral Ligament: A Randomized Controlled Trial. Arthroscopy 2019; 35:1130-1137. [PMID: 30871907 DOI: 10.1016/j.arthro.2018.11.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of the present randomized controlled trial was to compare 2 different medial patellofemoral ligament reconstruction (MPFL-R) techniques that utilize different femoral fixation principles, which could affect subjective clinical outcomes and surgical morbidity. METHODS Sixty patients were randomly assigned to 2 MPFL-R techniques: bone or soft-tissue fixation of the graft at the femoral condyle. Patients had operations performed between 2010 and 2015 at a single center. Indication for surgery was 2 or more patellar dislocations. When the bone fixation technique was used, the gracilis tendon was fixed with the use of an interference screw. When the soft-tissue fixation technique was used, the gracilis tendon was looped around the adductor magnus tendon. Both techniques used patella-graft fixation with drill holes in the medial patellar edge. Clinical outcomes were evaluated by means of Kujala, knee injury and osteoarthritis outcome, and pain scores before the operation and at 1- and 2-year follow-up examinations. Surgical morbidity was evaluated by pain on palpation along the reconstruction site. RESULTS Kujala scores were 88 and 89 for bone and soft-tissue fixation groups, respectively, with no difference between groups (P = .73). No significant differences in knee injury osteoarthritis outcome or pain scores were found. Analysis of surgical morbidity, defined as femoral-based tenderness overlying the fixation site, demonstrated that 13% and 12% of patients had significant tenderness at the reconstruction site after bone and soft-tissue MPFL-R, respectively. No patellar re-dislocations were observed in either group. CONCLUSIONS MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. Surgical morbidity was also similar between patients who had soft-tissue and those who had bone fixation MPFL-R. Soft-tissue femoral graft fixation does not result in inferior clinical outcomes compared with screw fixation, and it can be used safely for MPFL-R.
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Neri T, Parker DA, Beach A, Gensac C, Boyer B, Farizon F, Philippot R. Medial patellofemoral ligament reconstruction with or without tibial tubercle transfer is an effective treatment for patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2019; 27:805-813. [PMID: 30167754 DOI: 10.1007/s00167-018-5102-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The hypotheses were that medial patellofemoral ligament reconstruction (MPFLr) would improve the long-term symptoms of patellofemoral Instability (PFI) and control patellar tilt, based on computed tomography (CT), and that the addition of a TT transfer, when it is necessary, would not deteriorate the outcome. The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of a large series of MPFLr, either isolated or associated with a TT transfer. METHODS From 133 MPFLr with a minimum of 4 years postoperatively, three groups were defined: isolated MPFLr, MPFLr with tibial tubercle (TT) medialisation or MPFLr with TT medialisation and distalisation. IKDC and Kujala scores were evaluated. Patellar tilt was evaluated on the patient's preoperative and the last available radiograph, and on CT scan measurements performed preoperatively and at 6-month postoperatively. RESULTS The mean follow-up was 6.3 ± 1.7 years [4.1-10.3] and four patients reported recurrent patellar dislocation. Between pre and postoperative at last follow-up a significant improvement in IKDC and Kujala functional scores was observed (P < 0.01), with no difference between the three groups. Regarding patellar tilt, there were significant decreases in Laurin and Merchant angles and an improvement of the Maldague stage (P < 0.01). The CT analysis of patellar tilt also demonstrates a significant improvement of the patella tilt (P < 0.01). The control of the patella tilt was correlated with a good functional result (P < 0.01). CONCLUSION The MPFLr, whether isolated or associated with a TT transfer, provides good long-term clinical and radiological outcomes with a low rate of recurrence. The addition of a TT transfer, when necessary, results in the same good outcomes. This article provides a guide for surgeons evaluating PFI to choose the most appropriate procedure. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Thomas Neri
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France. .,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France. .,Sydney Orthopaedic Research Institute, Sydney, Australia.
| | | | - Aaron Beach
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Clara Gensac
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France
| | - Bertrand Boyer
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France
| | - Frederic Farizon
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France.,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France
| | - Remi Philippot
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France.,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France
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