Timing for Safe Return to Sport after Medial Patellofemoral Ligament Reconstruction: The Role of a Functional Test Battery

Feasibility of return to sports assessment 6 months after patellar instability surgery

BACKGROUND

The evidence regarding the usefulness of assessment tools to support decisions of return-to-sport after surgery for patellar instability is scarce. The purpose of this study was therefore to explore the feasibility of functional tests assessing readiness for return-to-sport six months after patellar stabilizing surgery. However, there is little evidence on what a functional assessment should include to support these decisions following surgery for patellar instability. Therefore the purpose of this study was to explore the feasibility of functional tests assessing readiness for return-to-sport six months after patellar stabilizing surgery.

METHODS

In this cross-sectional study a prospective cohort of 78 patients were subjected to a range of return-to-sport readiness tests at six months after surgery for patellar instability with an "a la carte" approach. Lower Quarter Y-Balance Test (YBT-LQ), single-legged hop tests and isokinetic strength tests were performed. In addition, self-reported function was measured with the Banff Patellofemoral Instability Instrument 2.0 (BPII) and Norwich Patellar Instability score (NPI). Return-to-sport clearance criteria were defined as: ≤4 cm YBT-LQ anterior reach difference between legs, leg-symmetry-index (LSI) ≥ 95% in the YBT-LQ composite score, mean sum score LSI ≥ 85% of all single-leg hop tests and LSI ≥ 90% in isokinetic quadriceps strength.

RESULTS

Sixty-four patients (82%) were able to complete all functional tests, while only eleven (14%) patients were deemed ready for return-to-sport, passing all return-to-sport clearance criteria. Patients with bilateral problems demonstrated worse performance in the contralateral leg, which resulted in higher LSI scores compared to individuals with unilateral instability. A supplementary finding was that the extent of surgery (MPFL-R only versus combined surgery) did not predict and mainly did not affect self-reported function or functional performance at the follow-up.

CONCLUSION

The functional assessment used in the current study seems feasible to conduct at six months after patellar stabilizing surgery. However, current suggested clearance standards and the use of leg-symmetry-index seems inappropriate for patients with patellar instability. Therefore, further exploration of appropriate tests and return-to-sport clearance criteria is justified.

TRIAL REGISTRATION

clinicaltrial.gov, NCT05119088. Registered 12.11.2021 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05119088 .

Clinical outcomes and return to sport after single-stage revision anterior cruciate ligament reconstruction by bone-patellar tendon autograft combined with lateral extra-articular tenodesis

PURPOSE

The anterior cruciate ligament reconstruction (ACLR) failure rate continues to increase. Involvement of a young population with a desire to return to sport, explains the increased need for ACLR (revACLR) revision. The aim of this study was to evaluate clinical outcome, complications, failure rate and return to sport of a single-stage revACLR using bone patellar tendon-bone (BTBT) combined with lateral extra-articular tenodesis (LET).

MATERIAL AND METHODS

A retrospective analysis was performed on 36 patients who underwent revACLR. Knee stability was assessed by Lachman and Pivot shift test. Objective anterior laxity was determined by KT-2000 arthrometer. The IKDC subjective, Lysholm, ACL-RSI Scores, level of sport activity and Forgotten Joint Score-12 were recorded.

RESULTS

Of 36 patients, we collected data from 17 who underwent single-stage revACLR with autologous BTBT combined with LET, performed using an extra-articular MacIntosh procedure as modified by Arnold-Coker. The side-to-side difference in Lachman test and Pivot shift test significantly improved postoperatively. The subjective IKDC, Lysholm and ACL-RSI significantly improved from 71.4 ± 9.03 to 92 ± 6.9, from 58.3 ± 19.3 to 66.8 ± 27.7 and from 50.4 ± 12.2 to 68.6 ± 24.5, respectively during the post-operative follow-up. Ten patients (58.8%) returned to their desired level of sport. One patient was considered a failure because of the postoperative laxity.

CONCLUSION

Single-stage revACLR with BPTB combined with LET is a safe procedure that shows good objective and subjective outcomes, and a high rate of return to the same level of sport. Reducing rotational instability and strain on intra-articular reconstructed structures results in a low rate of complications and failure.

Patients' experiences of living with patellar instability before and after surgery: a qualitative interview study

OBJECTIVES

To explore the experience of living with patellar instability before and after surgery.

DESIGN

Qualitative individual semistructured interviews of patients with patellar instability using a four-step thematic cross-case analysis strategy (systematic text condensation).

SETTING

Two orthopaedic units within two large Hospitals in Norway.

PARTICIPANTS

A convenience sample of 15 participants, aged between 16 and 32 years, who had undergone surgery for patellar instability within the last 6-12 months.

RESULTS

Participants offered rich and detailed descriptions of the impact and lived experience of patellar instability, including fear of new dislocations, increased awareness of the knee and adaptations to avoidance behaviour in everyday life both before and after surgery. The four major themes that emerged from the data were: (1) fear of patella dislocations governs everyday life activities, (2) adaptation to avoidance behaviour, (3) feeling different, misunderstood and stigmatised affects self-esteem and (4) feeling stronger, but still not fully confident in the knee after surgery.

CONCLUSIONS

These findings offer insight into the experience of living with patellar instability. Patients reported that the instability had major impacts on their everyday life, affecting ability to participate in social life and physical activities both before and after surgery. This may imply that an increased attention towards cognitive interventions may be useful in the management of patellar instability.

TRIAL REGISTRATION NUMBER

NCT05119088.

Protocols of rehabilitation and return to sport, and clinical outcomes after medial patellofemoral ligament reconstruction with and without tibial tuberosity osteotomy: a systematic review

PURPOSE

No consensus exists on rehabilitation programmes after medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tuberosity osteotomy (TTO). This systematic review examined the content and timeline of rehabilitation (weightbearing, range of motion [ROM] and exercise therapy) and return to sport (RTS), as well as patient-reported outcomes after MPFLR with or without TTO.

METHODS

The PubMed, Cochrane Library, Web of Sciences, CINAHL and SPORTDiscus databases were searched from inception to December 2021. Studies that reported postoperative rehabilitation programmes and patient-reported outcomes for patients aged ≥ 18 years who underwent MPFLR with or without concomitant TTO were included.

RESULTS

Eighty-five studies were included, 57 of which were case series and only one randomised controlled trial on rehabilitation programmes. Non-weightbearing was set within one week post-operatively in approximately 80% of weightbearing programmes for MPFLR without and with TTO. Joint immobilisation was set within one week post-operatively in 65.3% and 93.8% of programmes for MPFLR without and with TTO, respectively. Weightbearing and ROM (≤ 90°) restriction were within three weeks post-operatively for > 50% of the programmes. Quadriceps strengthening was the most cited exercise therapy (33 programmes), most often initiated within two weeks post-operatively. However, few other exercise programmes were cited (only nine programmes). RTS was mostly noted at six months post-operatively (35 programmes). The weighted mean Kujala score was 87.4 points.

CONCLUSION

Regardless of TTO addition to MPFLR, most studies restricted weightbearing and ROM only in the early post-operative period, with seemingly favourable clinical results. Limited information was available on post-operative exercise therapy.

Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport

PURPOSE

Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR.

METHODS

Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2 years.

RESULTS

One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6 months (range: 2-48 months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02).

CONCLUSION

Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10 months and post-operative Tegner score was noted to be modestly decreased from pre-injury level.

LEVEL OF EVIDENCE

IV.

Return to Sports and Patients' Rehabilitation Continuum After Deepening Trochleoplasty and Concomitant Patellar-Stabilizing Procedures: A Case Series of 111 Patients at 2 to 4 Years of Follow-up

BACKGROUND

There are few reports on the return to sports after complex patellar-stabilizing surgery.

PURPOSES

To evaluate patients' ability to return to sports and to investigate the extent to which the preoperative level of sports participation influences sports activity after deepening trochleoplasty (TP) and concomitant patellar-stabilizing procedures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2015 and April 2019, 144 patellar-stabilizing procedures, including deepening TP and medial patellofemoral ligament reconstruction or medial reefing with and without concomitant realignment procedures, were carried out in 142 patients. The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) and the Tegner activity score were used to assess patients' quality of life and sports activity level. In addition, a numerical analog scale was used to evaluate patellofemoral pain intensity during rest and activity and subjective knee joint function.

RESULTS

Outcomes were available for 111 patients (112 knees) (male/female, 77/34; mean age, 23.4 ± 7.8 years), yielding a 77.7% follow-up rate at a mean of 39.2 ± 9.9 months (range, 24-48 months). Two-thirds of the patients returned to their preoperative level of activity or higher, but their Tegner scores did not change significantly (4.5 ± 2.4 vs 4.7 ± 1.6; P = .365). Low-level athletes (preoperative Tegner score 0-4) participated at a higher level of sports activity (2.7 ± 1.4 to 4.1 ± 1.2; P < .0001), whereas higher-level athletes (preoperative Tegner score 5-10) participated at a lower level (6.8 ± 1.3 to 5.5 ± 1.7; P < .0001). The likelihood of returning to the preoperative activity level (Tegner score) was significantly higher in the low-level activity group than in the high-level activity group (P = .0001; 95% CI, 4.055-27.05; odds ratio, 10.47). All of the patient-reported outcome measures improved postoperatively, independent of the patients' age, sex, and body mass index.

CONCLUSION

Patients undergoing deepening TP and medial soft tissue stabilization with or without concomitant realignment surgery for complex patellar instability can expect good clinical results and a high rate of return to sports participation, with two-thirds of patients returning to their preoperative Tegner-level of activity or higher. However, higher-level athletes should be informed that their likelihood of returning to sports at the preoperative level or full participation at a competitive level is reduced.

Medial Patellofemoral Ligament Reconstruction: Use of All-Suture Anchors for Patellar Fixation and a Dynamic Femoral Attachment

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.