Rehabilitation After Medial Patellofemoral Ligament Reconstruction

Postoperative Bracing after Medial Patellofemoral Ligament Reconstruction

It is unclear if bracing is necessary after isolated medial patellofemoral ligament reconstruction (MPFLr) for recurrent patellar instability. We hypothesize that patients who did not use a brace will have similar outcomes to those who were braced postoperatively. A retrospective review of patients who underwent isolated MPFLr from January 2015 to September 2020 at a single institution was performed. Those with less than 6 weeks of follow-up were excluded. The braced group was provided a hinged-knee brace postoperatively until the return of quadriceps function, which was determined by the treating physical therapist (brace, "B"; no brace, "NB"). Time to straight leg raise (SLR) without lag, recurrent instability, and total re-operations were determined. Univariate analysis and logistic regression were used to evaluate outcomes (statistical significance, p < 0.05). Overall, 229 isolated MPFLr were included (B: 165 knees, 146 patients; NB: 64 knees, 58 patients). Baseline demographics were similar (all p > 0.05). Median time to SLR without lag was shorter in the NB group (41 days [interquartile range [IQR]: 20-47] vs. 44 days [IQR: 35.5-88.3], p = 0.01), while return to sport times were equivalent (B: 155 days [IQR: 127.3-193.8] vs. NB: 145 days [IQR: 124-162], p = 0.31). Recurrent instability rates were not significantly different (B: 12 knees [7.27%] vs. NB: 1 knee [1.56%], p = 0.09), but the re-operation rate was higher in the brace group (20 knees [12.1%] vs. 0 [0%], p = 0.001). Regression analysis identified brace use (odds ratio [OR]: 19.63, 95% confidence interval [CI]: 1.43-269.40, p = 0.026) and female patients (OR: 2.79, 95% CI: 1.01-7.34, p = 0.049) to be associated with needing reoperation. Recurrent instability rates and return to sport times were similar between patients who did or did not use a hinged knee brace after isolated MPFLr. Re-operation rates were higher in the braced group. Retrospective Comparative Study, Level III.

Medial Patellofemoral Ligament Reconstruction: A Case Report for an Integrated Rehabilitation Approach

Medial patellofemoral ligament (MPFL) reconstruction is a surgical treatment, primarily indicated for patients grappling with recurrent patellar instability stemming from traumatic injury or underlying anatomical anomalies. This abstract aims to elucidate the indispensable role of physiotherapy in the post-operative rehabilitation trajectory for individuals subjected to MPFL reconstruction. Physiotherapy emerges as a linchpin in securing a triumphant outcome, fostering the healing of patellar stability, augmentation of range of motion (ROM), and bolstering muscular strength while concurrently mitigating potential complications. The abstract accentuates salient facets of a physiotherapeutic regimen, encompassing prompt post-operative mobilization, meticulously tailored exercise paradigms, adept utilization of manual therapy modalities, and comprehensive patient education. Notably, this collaborative endeavor between orthopedic surgeons and physiotherapists is pivotal in optimizing patient convalescence, restoring them to their pre-injury functional acumen. A paramount emphasis is placed on individualized rehabilitation strategies, gradual and systematic exercise protocols, and patient adherence, thereby underscoring how the harmonious synergy between surgical and physiotherapeutic interventions augments the prospects of achieving a successful MPFL reconstruction outcome.

A modified Delphi consensus statement on patellar instability: part II

Aims

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Methods

This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous.

Results

Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus.

Conclusion

Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients

Purpose

Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries.

Methods

Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications.

Results

A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased.

Conclusions

Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth.

Level of evidence

Retrospective level III.

Surgical versus non-surgical interventions for treating patellar dislocation

BACKGROUND

Patellar (knee cap) dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. It affects up to 42/100,000 people, and is most prevalent in those aged 20 to 30 years old. It is uncertain whether surgical or non-surgical treatment is the best approach. This is important as recurrent dislocation occurs in up to 40% of people who experience a first time (primary) dislocation. This can reduce quality of life and as a result people have to modify their lifestyle. This review is needed to determine whether surgical or non-surgical treatment should be offered to people after patellar dislocation.

OBJECTIVES

To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL, Physiotherapy Evidence Database and trial registries in December 2021. We contacted corresponding authors to identify additional studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating primary or recurrent lateral patellar dislocation in adults or children.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were recurrent patellar dislocation, and patient-rated knee and physical function scores. Our secondary outcomes were health-related quality of life, return to former activities, knee pain during activity or at rest, adverse events, patient-reported satisfaction, patient-reported knee instability symptoms and subsequent requirement for knee surgery. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 10 studies (eight randomised controlled trials (RCTs) and two quasi-RCTs) of 519 participants with patellar dislocation. The mean ages in the individual studies ranged from 13.0 to 27.2 years. Four studies included children, mainly adolescents, as well as adults; two only recruited children. Study follow-up ranged from one to 14 years. We are unsure of the evidence for all outcomes in this review because we judged the certainty of the evidence to be very low. We downgraded each outcome by three levels. Reasons included imprecision (when fewer than 100 events were reported or the confidence interval (CI) indicated appreciable benefits as well as harms), risk of bias (when studies were at high risk of performance, detection and attrition bias), and inconsistency (in the event that pooled analysis included high levels of statistical heterogeneity). We are uncertain whether surgery lowers the risk of recurrent dislocation following primary patellar dislocation compared with non-surgical management at two to nine year follow-up. Based on an illustrative risk of recurrent dislocation in 348 people per 1000 in the non-surgical group, we found that 157 fewer people per 1000 (95% CI 209 fewer to 87 fewer) had recurrent dislocation between two and nine years after surgery (8 studies, 438 participants). We are uncertain whether surgery improves patient-rated knee and function scores. Studies measured this outcome using different scales (the Tegner activity scale, Knee Injury and Osteoarthritis Outcome Score, Lysholm, Kujala Patellofemoral Disorders score and Hughston visual analogue scale). The most frequently reported score was the Kujala Patellofemoral Disorders score. This indicated people in the surgical group had a mean score of 5.73 points higher at two to nine year follow-up (95% CI 2.91 lower to 14.37 higher; 7 studies, 401 participants). On this 100-point scale, higher scores indicate better function, and a change score of 10 points is considered to be clinically meaningful; therefore, this CI includes a possible meaningful improvement. We are uncertain whether surgery increases the risk of adverse events. Based on an assumed risk of overall incidence of complications during the first two years in 277 people out of 1000 in the non-surgical group, 335 more people per 1000 (95% CI 75 fewer to 723 more) had an adverse event in the surgery group (2 studies, 144 participants). Three studies (176 participants) assessed participant satisfaction at two to nine year follow-up, reporting little difference between groups. Based on an assumed risk of 763 per 1000 non-surgical participants reporting excellent or good outcomes, seven more participants per 1000 (95% CI 199 fewer to 237 more) reported excellent or good satisfaction. Four studies (256 participants) assessed recurrent patellar subluxation at two to nine year follow-up. Based on an assumed risk of patellar subluxation in 292 out of 1000 in the non-surgical group, 73 fewer people per 1000 (95% CI 146 fewer to 35 more) had patellar subluxation as a result of surgery. Slightly more people had subsequent surgery in the non-surgical group. Pooled two to nine year follow-up data from three trials (195 participants) indicated that, based on an assumed risk of subsequent surgery in 215 people per 1000 in the non-surgical group, 118 fewer people per 1000 (95% CI 200 fewer to 372 more) had subsequent surgery after primary surgery.

AUTHORS' CONCLUSIONS

We are uncertain whether surgery improves outcome compared to non-surgical management as the certainty of the evidence was very low. No sufficiently powered trial has examined people with recurrent patellar dislocation. Adequately powered, multicentre, randomised trials are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the pathological variations that may be relevant to both choice of these interventions.

Active exercise therapy improves the recovery of knee joint function and reduction of muscle atrophy after medial patellofemoral ligament reconstruction for recurrent patellar dislocation

OBJECTIVES

Medial patellofemoral ligament (MPFL) reconstruction is an important surgical therapy for recurrent patellar dislocation. However, few studies have focused on exercise therapy after MPFL reconstruction. Therefore, the first purpose was to compare the active and traditional postoperative exercise therapies on the recovery of knee joint function and reduction of muscle atrophy after MPFL reconstruction, and the second purpose was to compare the active and traditional postoperative exercise therapies on the patellar stability after MPFL reconstruction.

METHODS

The cases of 31 patients with recurrent patellar dislocation treated with patella double semi-tunnel anatomical MPFL reconstruction from February 2016 and February 2019 were retrospectively reviewed. The clinical outcomes, including the patellar tilt angle (PTA), lateral patellofemoral angle (LPFA), thigh circumference reduction, Kujala score, and Lysholm score, were compared between two groups (i.e., active exercise and traditional exercise groups) preoperatively, 3 months postoperatively, 6 months postoperatively, 12 months postoperatively, and 24 months postoperatively.

RESULTS

The Kujala score was significantly higher in the active exercise group than traditional exercise group 3 months postoperatively (80.06 vs. 74.80, P < 0.01), 6 months postoperatively (89.19 vs. 82.07, P < 0.01), 12 months postoperatively (91.43 vs. 86.60, P < 0.01), and 24 months postoperatively (92.50 vs. 90.27, P = 0.02). Similarly, there was a higher Lysholm score in the active exercise group compared with traditional exercise group 3 months postoperatively (81.25 vs. 76.53, P < 0.01), 6 months postoperatively (89.81 vs. 84.80, P < 0.01), 12 months postoperatively (93.25 vs. 88.40, P < 0.01), and 24 months postoperatively (93.69 vs. 90.67, P < 0.01). Significantly lower thigh circumference reduction was reported in the active exercise group compared with that in the traditional exercise group 3 months postoperatively (1.90 ± 0.57 vs. 2.45 ± 0.45, P < 0.01) and 6 months postoperatively (1.50 ± 0.31 vs. 1.83 ± 0.32, P < 0.01). No statistical difference was observed between the two groups in terms of PTA (P > 0.05) or LPFA postoperatively (P > 0.05).

CONCLUSIONS

Our results suggested that active exercise therapy might benefit the early recovery of knee joint function and reduction of muscle atrophy in patients with recurrent patellar dislocation after MPFL reconstruction.

Accelerated rehabilitation program following medial patellofemoral ligament reconstruction does not increase risk of recurrent instability

BACKGROUND

Rehabilitation protocols following medial patellofemoral ligament (MPFL) reconstruction were historically restrictive, with patients often immobilized and/or given weightbearing restrictions. However, more recently published protocols have been more aggressive. We compared patient-reported outcomes and recurrent dislocation risk between patients treated with a restrictive rehabilitation program (early post-operative bracing and weightbearing restrictions) and an accelerated rehabilitation protocol (no post-operative bracing or weightbearing restrictions) following MPFL reconstruction.

METHODS

Patients who underwent isolated MPFL reconstruction at an academic center between 2008 and 2016 were identified. Patient demographics, anatomical measurements, surgical details, and outcomes were collected. During this period, the rehabilitation protocol at the center transitioned from a restrictive to an accelerated rehabilitation protocol. Failure risk and patient-reported outcomes were compared based on rehabilitation protocol.

RESULTS

Of the163 isolated MPFL reconstructions performed during the study period, 123 (75%) were available for minimum one-year follow up at a mean of 4.0 years post-operative. Overall, 53 knees (43%) underwent the accelerated rehabilitation protocol and the remaining 70 knees (57%) underwent the restrictive protocol. There were 3 recurrent dislocations during the study period (2.4%), all of which occurred in the restrictive rehabilitation group. Multiple linear regression demonstrated that being in the accelerated rehabilitation group was not associated with poorer Knee injury and Osteoarthritis Outcome Score (KOOS) subscales controlling for age, sex, body mass index, Caton-Deschamps Index, tibial tubercle-trochlear groove distance, sulcus angle, MPFL graft choice, and length of follow-up.

CONCLUSION

An accelerated rehabilitation protocol without immobilization or weightbearing restrictions does not increase risk of recurrent patellar dislocation or poorer patient-reported outcome following isolated MPFL reconstruction.

Lateral Patellar Dislocation: A Critical Review and Update of Evidence-Based Rehabilitation Practice Guidelines and Expected Outcomes

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Nonoperative treatment of a lateral patellar dislocation produces favorable functional results, but as high as 35% of individuals experience recurrent dislocations.

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Medial patellofemoral ligament reconstruction is an effective treatment to prevent recurrent dislocations and yield excellent outcomes with a high rate of return to sport.

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Both nonoperative and postoperative rehabilitation should center on resolving pain and edema, restoring motion, and incorporating isolated and multijoint progressive strengthening exercises targeting the hip and knee.

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Prior to return to sports, both functional and isolated knee strength measurements should be used to determine leg symmetry strength and to utilize patient-reported outcome measures to assess the patient's perceived physical abilities and patellofemoral joint stability.

Online Rehabilitation Protocols for Medial Patellofemoral Ligament Reconstruction With and Without Tibial Tubercle Osteotomy Are Variable Among Institutions

Purpose

To compare and contrast the various rehabilitation protocols for medial patellofemoral ligament (MPFL) reconstruction and MPFL reconstruction plus tibial tubercle osteotomy (TTO) published online by academic orthopaedic surgery residency programs and private practice institutions throughout the United States.

Methods

We performed a systematic electronic search of MPFL reconstruction rehabilitation protocols in academic orthopaedic surgery residency programs in the United States using Google’s search engine (www.google.com) based on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA). Private practice organizations publishing MPFL reconstruction or MPFL reconstruction–TTO rehabilitation protocols that were found on the first page of search results were also included, but no comprehensive search for private practice protocols was performed. Protocols specifying an MPFL reconstruction with TTO were included for separate review because of altered weight-bearing status postoperatively. A list of comparative criteria was created to assess the protocols for the presence and timing of the various rehabilitation components.

Results

From the list of 189 U.S. academic residency programs, as well as additional private practice protocols found in the Google search, 38 protocols were included for review (31 protocols for isolated MPFL reconstruction and 7 protocols for MPFL reconstruction plus TTO). A return to full range of motion by week 6 was recommended by 15 (48.4%) of the isolated MPFL reconstruction protocols and 6 (85.7%) of the MPFL reconstruction–TTO protocols. Six weeks of knee brace wear was recommended by 13 isolated MPFL reconstruction protocols (43.3%) and 4 MPFL reconstruction–TTO protocols (57.1%). Moreover, 6 isolated MPFL reconstruction protocols (19.4%) and 3 MPFL reconstruction–TTO protocols (42.9%) recommended use of a patellar stabilizing brace postoperatively.

Conclusions

There is substantial variability among rehabilitation protocols after MPFL reconstruction, as well as MPFL reconstruction plus TTO, including postoperative range of motion, weight-bearing status, and time until return to sport. Furthermore, many online protocols from academic orthopaedic surgery residency programs and private practices in the United States fail to mention several of these parameters, most notably functional testing to allow patients to return to sport.

Clinical Relevance

Proper rehabilitation after MPFL reconstruction with or without TTO is an important factor to a patient’s postoperative outcome. This study outlines the variability in online rehabilitation protocols after MPFL reconstruction with or without TTO published online by academic residency programs and private practice institutions.

Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament

Most patellar dislocations are associated with disruption of the proximal medial patellar restraints (PMPRs). The PMPRs comprise the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL). Although isolated MPFL reconstruction is the most frequently performed procedure for the surgical management of recurrent dislocation, recent studies have shown that the MQTFL has a synergistic role with the MPFL in resisting lateral patellar displacement close to full extension. It has therefore been suggested that surgical techniques that gain the benefits of both proximal and distal PMPR biomechanical behavior may be best. This article describes an established technique for combined MPFL and MQTFL reconstruction using semitendinosus autograft.

Functional outcome after recurrent patellar dislocation : Comparison of two surgical techniques-Medial patellofemoral ligament reconstruction (MPFL) vs. Elmslie Trillat procedure

Background

There is no final consensus regarding the ideal surgical technique for the treatment of patellar dislocation. The aim of this retrospective pilot study was to describe muscle strength, body composition, self-reported physical performance, and pain in male patients after patellar dislocation treatment with two different surgical techniques: medial patellofemoral ligament (MPFL) reconstruction vs. the Elmslie-Trillat procedure.

Methods

Isokinetic testing of knee extensor muscles was performed using a Biodex System 3 pro dynamometer at an angular velocity of 60°/s. Body composition was measured with bioelectrical impedance analysis (Nutribox). Self-reported physical performance and pain were assessed by the SF-36 subscales of physical functioning, role physical and bodily pain. The outcome variables of peak torque normalized to participant’s body mass (Nm/kg), lean body mass, phase angle, self-reported physical performance, and pain were compared between the study groups.

Results

Of the 12 included male patients, 6 had been treated with MPFL reconstruction (age: median = 33 years, range = 18–38 years; BMI: median = 26 kg/m², range = 23–29) and 6 with the Elmslie-Trillat procedure (age: median = 26 years, range = 19–32 years; BMI: median = 23 kg/m², range = 19–28). No statistically significant differences were found between the groups in any outcome parameter of muscle strength, body composition, self-reported physical performance, or pain.

Conclusions

The results of the present pilot study revealed that MPFL reconstruction shows equal results to the Elmslie-Trillat procedure, with respect to isokinetic knee muscle strength, body composition, self-reported physical performance and pain in male patients suffering from recurrent patellar dislocation.

Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Medial Patellofemoral Ligament Reconstruction

Background:

Unlike the literature on anterior cruciate ligament reconstruction, studies on medial patellofemoral ligament (MPFL) reconstruction lack evidence-based guidelines regarding postoperative rehabilitation. An effective postoperative protocol may contribute greatly to a successful outcome following MPFL reconstruction, yet the quality and variability of these published protocols remain unknown.

Purpose:

To assess the quality and variability of MPFL rehabilitation protocols publicly available on the internet and associated with US academic orthopaedic programs.

Study Design:

Systematic review.

Methods:

All available isolated MPFL reconstruction rehabilitation protocols from US academic orthopaedic programs participating in the Electronic Residency Application Service were collected and included in this review. These protocols were evaluated for inclusion of various rehabilitation components, the timing of suggested initiation of these activities, and whether the protocol used evaluation-based guidelines.

Results:

A total of 27 protocols were included. Of these, 25 (93%) recommended immediate postoperative bracing. Time to initiation of full weightbearing ranged from 2 to 8 weeks. The most common strengthening exercises endorsed were quadriceps sets (89%), straight-legged raise (85%), and leg press (81%). The most common proprioception exercises endorsed were balance board (41%), single-legged balance (41%), and TheraBand control (33%). The median time suggested to return to play was 17 weeks. No functional test appeared in the majority of the protocols. Of the 27 protocols, 20 (74%) used evaluation-based guidelines.

Conclusion:

There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction. This lack of clear guidelines can cause confusion among patients, therapists, and surgeons, leading to suboptimal patient outcomes and making it difficult to compare outcomes across the literature.

Concomitant Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Osteotomy Do Not Increase the Incidence of 30-Day Complications: An Analysis of the NSQIP Database

Background:

Lateral patellar dislocations account for 2% to 3% of total knee injuries, especially in adolescents. Depending on the anatomic abnormality contributing to lateral patellar instability, medial patellofemoral ligament reconstruction (MPFLR) and/or tibial tubercle osteotomy (TTO) may be indicated.

Purpose:

To assess the risk of adverse events (AEs) after TTO, MPFLR, and concomitant MPFLR and TTO.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent MPFLR, TTO, and concomitant MPFLR and TTO between 2005 and 2016 were identified through the American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database. Medical complications (eg, surgical site infection and deep vein thrombosis), readmission rates, and extended hospital stay within 30 days of the procedure were recorded. Outcomes were compared with bivariate and multivariate Poisson regression.

Results:

Out of 882 patients, 617 (70.0%) underwent isolated MPFLR, 170 (19.3%) underwent TTO, and 95 (10.8%) underwent concomitant MPFLR and TTO. The operative time for concomitant MPFLR and TTO was significantly longer (122 ± 45 minutes) compared with isolated MPFLR (97 ± 55 minutes; P < .001) and isolated TTO (89 ± 51 minutes; P < .001). There were 32 AEs (3.6%), with 10 AEs in the isolated TTO group (5.9%), 18 AEs in the isolated MPFLR group (2.9%), and 4 AEs in the MPFLR + TTO group (4.2%). There was no significant difference in the rate of AEs between the isolated MPFLR and isolated TTO groups (P = .1), isolated MPFLR and MPFLR + TTO groups (P = .5), and isolated TTO and MPFLR + TTO groups (P = .8). Diabetes mellitus was associated with an increased risk of developing an AE (odds ratio, 4.0; P = .003), and hypertension resulted in an increased risk of an extended hospital stay (odds ratio, 4.0; P = .010).

Conclusion:

While concomitant MPFLR and TTO significantly increased operative time, there was no difference in the rate of AEs, extended hospital stay, and readmissions within 30 days after isolated MPFLR, isolated TTO, and concomitant MPFLR and TTO.

Early functional rehabilitation after patellar dislocation-What procedures are daily routine in orthopedic surgery?

INTRODUCTION

Patellar dislocation and rupture of the medial patellofemoral ligament (MPFL) are frequently seen in daily orthopedic practice. Besides initial non-surgical treatment, surgery and subsequent rehabilitation are crucial for restoring stability in the femoropatellar joint. This study investigated current rehabilitation strategies after patellar dislocation because knowledge on this topic has been severely limited so far.

MATERIALS AND METHODS

The current rehabilitation protocols of 42 orthopedic and trauma surgical institutions were analyzed regarding their recommendations on weight bearing, range of motion (ROM), and use of movement devices and orthosis. All protocols for conservative treatment and postoperative rehabilitation after MPFL reconstruction were compared. Descriptive and statistical analyses were carried out when appropriate.

RESULTS

The different rehabilitation strategies for conservative and surgical treatment after patellar dislocation showed a tendency towards earlier functional rehabilitation after surgical MPFL reconstruction than after conservative treatment. Both surgical and conservative treatment involved initial restrictions in weight bearing, ROM, and use of movement devices and orthosis at the beginning of rehabilitation. The rehab protocols showed a significant earlier full weight bearing after surgical MPFL reconstruction (p > 0.001). Due to the presence of other parameters for early functional treatment, the absence of an indication for using orthosis (surgical: 44%, conservative: 33%; p = 0.515) or start of unlimited ROM of the knee (surgical: 4.9 weeks, conservative: 5.7 weeks; p = 0.076) showed by trend an earlier functional strategy after MPFL reconstruction than after conservative therapy.

CONCLUSIONS

Both conservative and surgical treatment after patellar dislocation showed restrictions in the early phase of the rehabilitation. Earlier functional therapy was more common after MPFL reconstruction than after conservative treatment. Further clinical and biomechanical studies on rehabilitation strategies after patellar dislocation are needed to improve patient care und individualized therapy.

Rehabilitation variability following medial patellofemoral ligament reconstruction

BACKGROUND

Medial patellofemoral ligament (MPFL) reconstruction is an increasingly utilized surgical option for recurrent patellar instability. Recent studies have highlighted the potential benefits of accelerated functional rehabilitation; however, no validated MPFL rehabilitation guidelines currently exist.

OBJECTIVE

To assess the variability of MPFL reconstruction rehabilitation protocols published online by academic orthopaedic programs.

METHODS

Online MPFL rehabilitation protocols from U.S. teaching orthopaedic programs were reviewed. A comprehensive scoring rubric was developed to assess each protocol for both the presence of various rehabilitation components and the timing of their introduction.

RESULTS

Thirty-one protocols (20%) were identified from 155 U.S. academic orthopaedic programs. Thirty protocols (97%) recommended immediate postoperative knee bracing. Twenty protocols (65%) allowed for weight-bearing as tolerated using crutches immediately postoperatively, whereas seven protocols (23%) recommended partial weight-bearing and four protocols (13%) recommended toe-touch weight-bearing. For those protocols advising partial and toe-touch weight-bearing, advancement to full weight-bearing was achieved at averages of 4.7 (range, 3-8) weeks and 6.3 (range, 6-7) weeks, respectively. There was considerable variation in range of motion (ROM) goals; however, most protocols (97%) recommended achieving 90 degrees of knee flexion at an average of 1.4 (range, 0-6) weeks. Significant diversity was found in the inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular exercises. Twenty-five protocols (81%) recommended return to training after completing specific athletic criteria.

CONCLUSIONS

A minority of U.S. teaching orthopaedic institutions publish MPFL reconstruction rehabilitation protocols online. Furthermore, there is a high degree of variability in both the composition and timing of rehabilitation modalities across these protocols.