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White AE, James EW, Jahandar A, Jones RH, Fabricant PD. Effect of Medial Patellofemoral Complex Reconstruction Technique on Patellofemoral Contact Pressure, Contact Area, and Kinematics. Am J Sports Med 2024:3635465241252818. [PMID: 38872411 DOI: 10.1177/03635465241252818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is considered by many to be the gold standard to treat lateral patellar instability; however, some investigators have reported good clinical results after isolated medial quadriceps tendon-femoral ligament (MQTFL) reconstruction or a combined MPFL/MQTFL reconstruction. A handful of studies have preliminarily investigated the biomechanical consequences of these various medial patellar stabilizing procedures. Despite this, no existing study has included multiple medial patellofemoral complex (MPFC) reconstructions and assessment of lateral patellar translation at distinct flexion angles. HYPOTHESIS Combined MPFL/MQTFL reconstruction would restore patellofemoral contact areas, forces, and kinematics closest to the native state compared with isolated reconstruction of the MPFL or MQTFL alone. STUDY DESIGN Controlled laboratory study. METHODS Ten adult cadaveric knee specimens were prepared and analyzed under 5 different conditions: (1) intact state, (2) transected MPFC, (3) isolated MPFL reconstruction, (4) isolated MQTFL reconstruction, and (5) combined MPFL/MQTFL reconstruction. Patellar tilt, lateral patellar translation, patellofemoral contact forces, and patellofemoral contact areas were measured in each condition from 0° to 80° through simulated knee flexion using a custom servohydraulic load frame with pressure sensor technology and a motion capture system for kinematic data acquisition. RESULTS The isolated MPFL, isolated MQTFL, and combined MPFL/MQTFL reconstruction conditions produced significantly less lateral patellar tilt compared with the transected MPFC state (P < .05). No statistically significant differences were found when each reconstruction technique was compared with the intact state in patellar tilt, lateral patellar translation, contact forces, and contact areas. CONCLUSION All 3 reconstruction techniques (isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction) restored native knee kinematics, contact forces, and contact areas without overconstraint. CLINICAL RELEVANCE Isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction all restore patellofemoral stability comparable with the intact MPFC state without the overconstraint that could be concerning for increasing risk of patellofemoral arthritis.
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Affiliation(s)
| | - Evan W James
- Raleigh Orthopaedic, Raleigh, North Carolina, USA
| | | | - Ruth H Jones
- Hospital for Special Surgery, New York, New York, USA
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Ryan PC, Ching IC, Ierulli VK, Pickett K, Mulcahey MK. Fear of Re-Injury, Psychological Factors, and Sport Played Have Negative Impact on Return to Sport Following Medial Patellofemoral Ligament Reconstruction for Patellar Instability. Arthroscopy 2024:S0749-8063(24)00399-2. [PMID: 38849062 DOI: 10.1016/j.arthro.2024.05.022] [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: 12/21/2023] [Revised: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 06/09/2024]
Abstract
PURPOSE To analyze factors that affect return to sport after medial patellofemoral ligament reconstruction (MPFLR), such as psychological factors, sport played, and a positive apprehension test following surgery, and to determine the average return to sport rates and time to return to sport. METHODS A literature search was conducted according to PRISMA guidelines. Included studies met the following criteria: patients underwent MPFLR for patellar instability, return to sport was recorded, and a factor that affected return to sport was mentioned. Search terms included medial patellofemoral ligament, tibial tubercle osteotomy, tibial tubercle transfer, return to play, and return to sport. RESULTS 18 of 632 identified studies met inclusion criteria. 1,072 patients that underwent MFPLR were recorded. Return to sport rates and mean/median time ranged from 60.0-100% and 3-10.4 months, respectively. 55.6-84.0% of patients returned to sport without decreasing level of competition. Six of 12 studies (50.0%) reported fear of re-injury as the top reason for patients not returning or returning at a lower level of sport. Volleyball/handball had the lowest return to the same level following surgery (18.2-50.0%). CONCLUSION Athletes that underwent MPFLR following recurrent patellar instability returned to sport at a range of 60.0-100%. Return to sport at the same level or higher was found to have a lower maximum rate at 55.6-84.0%. Fear of re-injury and sport played were found to have a substantial impact on ability to return to sport. Surgeons can use this information to advise patients on expectations following surgery. LEVEL OF EVIDENCE IV, systematic review of level III and IV studies.
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Affiliation(s)
| | | | - Victoria K Ierulli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Keith Pickett
- Rudolph Matas Library of the Health Sciences, Tulane University School of Medicine, New Orleans, LA
| | - Mary K Mulcahey
- Department of Orthopedic Surgery and Rehabilitation, Loyola University Medical Center.
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Parikh SN, Nemunaitis J, Wall EJ, Cabatu C, Gupta R, Veerkamp MW. Midterm Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome. Orthop J Sports Med 2024; 12:23259671241241096. [PMID: 38845609 PMCID: PMC11155334 DOI: 10.1177/23259671241241096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 06/09/2024] Open
Abstract
Background Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown. Purpose To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes. Study Design Case series; Level of evidence, 4. Methods In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes-including postoperative complications-were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)-including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score-were collected, and factors affecting PRO scores were analyzed. Results The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome. Conclusion At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.
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Affiliation(s)
- Shital N. Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Nemunaitis
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, USA
| | - Eric J. Wall
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Rajul Gupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Bram JT, Tracey OC, Lijesen E, Li DT, Chipman DE, Retzky JS, Fabricant PD, Green DW. Simultaneous MPFL reconstruction and guided growth result in low rates of recurrent patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2024; 32:1105-1112. [PMID: 38469940 DOI: 10.1002/ksa.12134] [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: 10/31/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE Implant-mediated guided growth (IMGG) is used to address coronal plane deformity in skeletally immature patients. Few studies have reported on IMGG and simultaneous medial patellofemoral ligament (MPFL) reconstruction for paediatric patients with concurrent genu valgum and patellofemoral instability (PFI). This study aimed to report on the outcomes of these simultaneous procedures. MATERIALS AND METHODS This was a retrospective review of paediatric patients undergoing simultaneous MPFL reconstruction and IMGG between 2016 and 2023. Mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle (HKA) and mechanical axis deviation (MAD) were measured on full-length hip-to-ankle plain radiographs. Measurements were taken preoperatively, prior to implant removal and/or at final follow-up with minimum 1-year clinical follow-up. RESULTS A total of 25 extremities in 22 patients (10 female) underwent simultaneous IMGG and MPFL reconstruction. The mean age at surgery was 12.6 ± 1.7 years. The mean duration of implant retention was 18.6 ± 11.3 months. Nineteen extremities (76%) underwent implant removal by final follow-up. Preoperative HKA corrected from a mean of 5.8 ± 2.3° to -0.8 ± 4.5° at implant removal or final follow-up (p < 0.001), with mLDFA and MAD similarly improving (both p < 0.001). HKA corrected a mean of 0.7 ± 0.9° per month, while mLDFA and MAD corrected a mean of 0.5 ± 0.6°/month and 2 ± 3 mm/month, respectively. At the time of implant removal or final follow-up, 88% of patients demonstrated alignment within 5° of neutral. Only one extremity experienced subsequent PFI (4%). For 14 patients who underwent implant removal with further imaging at a mean of 7.8 ± 4.9 months, only one patient (7%) had a valgus rebound to an HKA > 5°. CONCLUSION Simultaneous MPFL reconstruction and IMGG provided successful correction of lower extremity malalignment with only one recurrence of PFI. This approach is a reliable surgical option for skeletally immature patients with genu valgum and PFI. LEVEL OF EVIDENCE Level 4 case series.
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Affiliation(s)
- Joshua T Bram
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Olivia C Tracey
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Emilie Lijesen
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Don T Li
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Danielle E Chipman
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Julia S Retzky
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Peter D Fabricant
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Klueh MP, Swany LM, Troost JP, Crawford EA. Return to Sports Rates in Pediatric Patients After Bilateral Versus Unilateral Medial Patellofemoral Ligament Reconstruction. Am J Sports Med 2024; 52:1527-1534. [PMID: 38600806 DOI: 10.1177/03635465241240154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Patellofemoral instability commonly occurs during sports activities. The return to sports (RTS) rate for pediatric patients after bilateral medial patellofemoral ligament reconstruction (MPFLR) is unknown. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate RTS outcomes for pediatric patients undergoing bilateral MPFLR. It was hypothesized that (1) fewer pediatric patients would RTS after bilateral MPFLR compared with unilateral MPFLR and that (2) for those in the bilateral cohort who were able to RTS, fewer patients would attain the same level of play as or higher level than the preinjury level. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We prospectively collected RTS data on retrospectively identified matched cohorts of patients aged ≤18 years who underwent unilateral and bilateral MPFLR. We matched each participant with bilateral MPFLR at a 1 to 2 ratio with a participant with unilateral MPFLR by concomitant procedure, age, and sex. Postoperative complications and preoperative imaging measurements were collected from medical records. Patient-reported outcomes were obtained using a current Single Assessment Numeric Evaluation score collected at the time of primary outcome data. RESULTS We matched 16 participants (mean age, 14 years) who underwent bilateral MPFLR to 32 participants (mean age, 14.3 years) in a corresponding unilateral MPFLR cohort. We found a significant decrease in RTS rates for pediatric patients after bilateral MPFLR when compared with unilateral MPFLR (69% vs 94%; P = .03). Among those who returned to sports, there was no difference in the level of play achieved. For participants who did not RTS or returned at a lower level of play after bilateral MPFLR, 57% cited fear of reinjury as the primary reason. There were no differences in postoperative complications or current Single Assessment Numeric Evaluation scores between cohorts. The bilateral cohort had a significantly higher Caton-Deschamps index compared with the unilateral cohort, although the absolute difference was small (1.3 vs 1.2; P = .005). CONCLUSION We found that pediatric patients have a lower RTS rate after bilateral MPFLR when compared with a matched unilateral MPFLR cohort. No differences in the level of play were achieved among those who returned to sports. Fear of reinjury was a commonly cited reason for not returning to sports.
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Affiliation(s)
- Michael P Klueh
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lauren M Swany
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Eileen A Crawford
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
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Huo Z, Hao K, Fan C, Niu Y, Bai H, Bai W. Derotational distal femur osteotomy with medial patellofemoral ligament reconstruction can get good outcomes in the treatment of recurrent patellar dislocation with excessive TT-TG and increased femoral anteversion. Front Surg 2024; 11:1392947. [PMID: 38660587 PMCID: PMC11039896 DOI: 10.3389/fsurg.2024.1392947] [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: 03/04/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024] Open
Abstract
Background Surgery is the main treatment for recurrent patellar dislocation (PD). However, due to the complexity of anatomical factors, there is still a lack of consensus on the choice of combined surgical methods. This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament reconstruction combined with derotational distal femur osteotomies (MPFLR + DDFO) and combined with tibial tubercle osteotomies (MPFLR + TTO) for recurrent PD with increased femoral anteversion angles (FAA) and excessive tibial tubercle-trochlear groove (TT-TG) distance. Methods In this retrospective analysis, MPFLR + DDFO and MPFLR + TTO patients from 2015 to 2020 were included. Group A (MPFLR + DDFO, n = 42) and B (MPFLR + TTO, n = 46) were formed. Clinical outcomes included physical examinations, functional outcomes (Kujala, Lysholm, International Knee Documentation Committee (IKDC), visual analog scale (VAS) and intermittent and persistent osteoarthritis pain scale (ICOAP), Tegner scores), and complications. The Caton-Deschamps index (CD-I), patellar title angle, patellar congruence angle, patella-trochlear groove distance, TT-TG distance, and FAA were used to assess radiological outcomes. Results All clinical outcomes improved significantly in both groups, but Group A had significantly better postoperative scores than Group B (Kujala: 89.8 ± 6.4 vs. 82.9 ± 7.4, P < 0.01; Lysholm: 90.9 ± 5.1 vs. 81.3 ± 6.3, P = 0.02; IKDC: 87.3 ± 9.0 vs. 82.7 ± 8.0, P < 0.01; Tegner: 6.0 (5.0, 9.0) vs. 5.0 (4.0, 8.0), P = 0.01). However, there was no significant difference in the VAS and ICOAP scores between the two groups. No dislocation recurrences occurred. Radiological outcomes improved significantly in both groups, but Group A had better outcomes. After surgery, the patellar height of 88.5% (23/26) patients in Group A and 82.8% (24/29) patients in Group B was restored to normal (the Caton-Deschamps index <1.2). Conclusions Both MPFLR + TTO and MPFLR + DDFO obtained satisfactory clinical and radiological outcomes in the treatment of recurrent PD with increased FAA and excessive TT-TG. However, the outcomes of MPFLR + DDFO were better and should be considered a priority. MPFLR + TTO may be not necessary for such patients.
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Affiliation(s)
- Zhenhui Huo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kuo Hao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chongyi Fan
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Haotian Bai
- School of Basic Medical Science, Hebei University, Baoding, Hebei, China
| | - Weixia Bai
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Camanho GL, Gobbi RG, Helito CP, Moreira da Silva AG, Machado de Oliveira G. Medial Patellofemoral Ligament Reconstruction Using the Medial Third of the Patellar Tendon: Camanho's Technique. Arthrosc Tech 2024; 13:102913. [PMID: 38690355 PMCID: PMC11056719 DOI: 10.1016/j.eats.2024.102913] [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: 09/24/2023] [Accepted: 12/08/2023] [Indexed: 05/02/2024] Open
Abstract
The reconstruction of the medial patellofemoral ligament (MPFL) is an essential procedure in the surgical treatment of patellar instability. The medial third of the patellar tendon is a good graft option for this reconstruction, maintaining the insertion of the graft in the patella, with no need for hardware for patellar fixation. The objective of this article is to describe the MPFL reconstruction technique with the patellar tendon graft.
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Affiliation(s)
- Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Andre Giardino Moreira da Silva
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gabriel Machado de Oliveira
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Tan SHS, Sin QS, Tan LYH, Lim AKS, Hui JH. Combination of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for patellofemoral instability provides good middle- to long-term outcomes in adolescents. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1551-1556. [PMID: 38280075 DOI: 10.1007/s00590-024-03837-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/05/2024] [Indexed: 01/29/2024]
Abstract
PURPOSE There are limited studies that have reported the middle- to long-term outcomes of combined procedures consisting of more than two procedures for patellofemoral instability. The current study aims to investigate and report the middle- to long-term outcomes of a combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for patellofemoral instability in patients aged 18 years and below. METHODS In the cohort study, all patients aged 18 years old or younger who underwent a combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for recurrent patellofemoral instability were included. RESULTS A total of 21 patients were included in the study. All patients had no further patellofemoral dislocation, pain and apprehension following the 4-in-1 surgery (p < 0.01). There was a significant improvement in the Kujala score from 36.1 (SD 12.9) pre-operatively to 93.1 (SD 3.6) post-operatively (p < 0.001). The patients also had a statistically significant improvement in their radiological factors, including the patellar tilt angle (p < 0.001), sulcus angle (p = 0.001), trochlear groove depth (p = 0.041), tibial tubercle-trochlear groove distance (p < 0.001) and Caton-Deschamps index (p = 0.001). CONCLUSION A combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release leads to good middle- to long-term subjective, functional and radiographic outcomes for patients with recurrent patellofemoral instability and underlying predisposing factors of increased TT-TG distance of more than 20 mm, Dejour B or D trochlear dysplasia and medial patellofemoral ligament rupture. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Hospital Sports Centre, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119074, Singapore.
| | - Qinxiang Shant Sin
- Department of Orthopaedic Surgery, National University Hospital Sports Centre, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119074, Singapore
| | - Luke Yi Hao Tan
- Department of Orthopaedic Surgery, National University Hospital Sports Centre, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119074, Singapore
| | - Andrew Kean Seng Lim
- Department of Orthopaedic Surgery, National University Hospital Sports Centre, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119074, Singapore
| | - James Hoipo Hui
- Department of Orthopaedic Surgery, National University Hospital Sports Centre, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119074, Singapore
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Shankar DS, DeClouette B, Avila A, Vasavada KD, Lan R, Strauss EJ, Jazrawi LM, Alaia MJ, Gonzalez-Lomas G, Campbell KA. Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study. J ISAKOS 2024:S2059-7754(24)00053-1. [PMID: 38490437 DOI: 10.1016/j.jisako.2024.03.008] [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: 07/03/2023] [Revised: 02/01/2024] [Accepted: 03/09/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p = 0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p = 0.47), return to sport (MQTFLR 50%, MPFLR 75%, p = 0.61), return to work (MQTFLR 100%, MPFLR 88%, p = 1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p = 0.31). CONCLUSION There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dhruv S Shankar
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Brittany DeClouette
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Amanda Avila
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Kinjal D Vasavada
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Rae Lan
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Eric J Strauss
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Laith M Jazrawi
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Guillem Gonzalez-Lomas
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Kirk A Campbell
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA.
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Bachman DR, Phillips D, Veerkamp MW, Chipman DE, Wall EJ, Ellington MD, Friel NA, Schlechter JA, Green DW, Masquijo J, Parikh SN. MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum. Am J Sports Med 2024; 52:698-704. [PMID: 38349668 DOI: 10.1177/03635465231222934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN Case series; Level of evidence, 4. METHODS In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.
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Affiliation(s)
- Daniel R Bachman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dayna Phillips
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Eric J Wall
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Nicole A Friel
- Shriners Hospitals for Children, Sacramento, California, USA
| | | | | | | | - Shital N Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Tomasevich KM, Kantor AH, Metz AK, Hanson IT, Froerer DL, Rosenthal RM, Aoki SK. Mid-term outcomes of temporary medial distal femoral hemiepiphysiodesis with and without medial patellofemoral ligament repair for recurrent patellar instability in skeletally immature patients with genu valgum. J Pediatr Orthop B 2024; 33:119-129. [PMID: 37610091 DOI: 10.1097/bpb.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Genu valgum contributes to patellar instability, though outcomes following temporary hemiepiphysiodesis via eight plating are less understood. The purpose of this study was to evaluate the outcomes and need for additional procedures following temporary hemiepiphysiodesis for the treatment of pediatric genu valgum and patellar instability, as well as evaluating the utility of a concurrent medial patellofemoral ligament (MPFL) repair. Patients who underwent medial distal femoral epiphysiodesis for the treatment of genu valgum and recurrent patellar instability were identified. Inclusion criteria were minimum 1-year follow-up and lack of concurrent ligamentous reconstruction. Patients were contacted to complete a questionnaire which included the International Knee Documentation Committee (IKDC) form and questions pertaining to knee function and patient satisfaction. Thirty-one patients aged 12.0 ± 1.9 years underwent 47 guided growth procedures and were included in final analysis. Seventeen knees (36%) required subsequent surgery for patellar instability. All patients requiring subsequent surgery were female, compared with 70% of patients not requiring subsequent surgery ( P = 0.017). The MPFL repair group underwent fewer subsequent procedures to address instability, though this difference was NS (17 vs. 46%, P = 0.318). Mean IKDC score at 5.3 years follow-up among 18 survey respondents was 78.6. Medial distal femoral hemiepiphysiodesis may partially address recurrent patellar instability in skeletally immature patients with genu valgum. Concurrent MPFL repair may minimize the need for subsequent procedures to address recurrent instability. While correcting alignment may be helpful, patients should be aware of the potential need for further patellar instability surgery. Level of evidence: IV, case series.
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Affiliation(s)
| | - Adam H Kantor
- Department of Orthopaedic Surgery, University of Utah
| | - Allan K Metz
- Department of Orthopaedic Surgery, University of Utah
| | | | - Devin L Froerer
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
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12
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Schaver AL, Tranovich MA, O'Reilly OC, Bollier MJ, Duchman KR, Wolf BR, Westermann RW. Postoperative Bracing after Medial Patellofemoral Ligament Reconstruction. J Knee Surg 2024. [PMID: 38113911 DOI: 10.1055/a-2232-4856] [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] [Indexed: 12/21/2023]
Abstract
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.
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Affiliation(s)
- Andrew L Schaver
- Department of Orthopedic Surgery, Marshall University, Huntington, West Virginia
| | - Meaghan A Tranovich
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Olivia C O'Reilly
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Matthew J Bollier
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Kyle R Duchman
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Brian R Wolf
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Robert W Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
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13
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Mitani G, Serigano K, Takagaki T, Hamahashi K, Takizawa D, Sogo Y, Sato M, Watanabe M. MPFL Reconstruction Combined with a Modified Elmslie-Trillat Procedure for Recurrent Patellofemoral Instability. J Knee Surg 2024; 37:167-174. [PMID: 36539214 DOI: 10.1055/a-2001-6565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Several combined procedures have been reported for treating recurrent patellofemoral instability (RPI) with various types and severity of morphological abnormalities, but none have identified absolute threshold values as indications for surgery. We performed medial patellofemoral ligament (MPFL) reconstruction combined with a modified Elmslie-Trillat (ET) procedure on 24 knees (10 male and 11 female patients) to treat RPI with morphological abnormalities corresponding to elevated tibial tubercle-trochlear groove (TT-TG) distance, significant patella alta, and trochlear dysplasia. The inclusion criteria were RPI with morphological abnormalities corresponding to one or more of the following: sulcus angle > 160 degrees, trochlear dysplasia of Dejour classification C or D, Caton-Deschamps index > 1.5, lateral shift ratio > 50%, congruence angle > 15 degrees, or TT-TG distance > 20 mm, including habitual dislocation of the patella. Skeletally immature patients and those with congenital dislocation of the patella were excluded. The Kujala score, International Knee Documentation Committee subjective score, Knee Injury and Osteoarthritis Outcome score (KOOS), and each item of the KOOS improved significantly after surgery. Patellar apprehension sign was present preoperatively in all cases, but all disappeared postoperatively. No instance of postoperative redislocation was observed. On radiographic examination, the mean Q angle, tilting angle, lateral shift ratio, congruence angle, Caton-Deschamps index, Insall-Salvati index, and TT-TG distance improved significantly after surgery. There were no significant differences in sulcus angle after surgery. These results suggest MPFL reconstruction combined with a modified ET procedure provides satisfactory outcomes based on radiological and clinical evaluations for RPI with morphological abnormalities corresponding to elevated TT-TG distance, significant patella alta, and trochlear dysplasia.
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Affiliation(s)
- Genya Mitani
- Department of Orthopaedic Surgery, Tokai University Oiso Hospital, Naka-gun, Kanagawa, Japan
| | - Kenji Serigano
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Tomonori Takagaki
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kosuke Hamahashi
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daichi Takizawa
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Yasuyuki Sogo
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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14
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Runer A, Klotz S, Schneider F, Egelseer T, Csapo R, Hoser C, Abermann E, Mayr R, Raas C, Attal R, Arora R, Fink C, Liebensteiner M. Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft. Arthroscopy 2024; 40:438-445. [PMID: 37479150 DOI: 10.1016/j.arthro.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT). METHODS All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs. RESULTS A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P = .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P = .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P = .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P = .001). CONCLUSIONS GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years' postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Stefan Klotz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friedemann Schneider
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tim Egelseer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | - Christin Hoser
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | | | - Raul Mayr
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Raas
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rene Attal
- Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, LKH Feldkirch, Austria
| | - Rohit Arora
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | - Michael Liebensteiner
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopädie Knie & Fuß im Zentrum, Innsbruck, Austria
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15
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Perez AR, Coladonato C, Sonnier JH, Saucedo ST, Avendano JP, Corvi J, Campbell M, Tjoumakaris FP, Cohen SB, Ciccotti MC, Freedman KB. Patients With First-Time or Recurrent Patellar Dislocation Have a Similar High Rate and Extent of Articular Cartilage Injury Observed on Magnetic Resonance Imaging. Arthrosc Sports Med Rehabil 2024; 6:100849. [PMID: 38261848 PMCID: PMC10794921 DOI: 10.1016/j.asmr.2023.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/20/2023] [Indexed: 01/25/2024] Open
Abstract
Purpose To use magnetic resonance imaging (MRI) scans to compare the prevalence of articular cartilage damage in patients with a single patellar dislocation versus those with multiple dislocations and to compare the locations and severity of chondral injury between the groups. Methods Patients with patellar dislocation between January 2017 and July 2021 were retrospectively identified. Patients with a documented history of patellar dislocation and an MRI scan of the affected knee were included. Patients with articular cartilage injury prior to the dislocation event were excluded. Articular cartilage injury was graded using a validated system: AMADEUS (Mean Total Area Measurement and Depth & Underlying Structures). Caton-Deschamps Index (CDI) scores and Dejour classifications of trochlear dysplasia were also collected. Data were calculated by performing t tests, Mann-Whitney tests, and χ2 or Fisher Exact tests to calculate P values for categorical data. Results In total, 233 patients were included: 117 with primary dislocations and 116 with recurrent dislocations. Articular cartilage injuries were present in 51 patients with primary dislocations (43.6%) and 68 patients with recurrent dislocations (58.6%, P = .026). On comparison of the groups, the recurrent group contained a significantly larger proportion of female patients (65.5% vs 46.2%, P = .004). There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between groups (P = .231). Caton-Deschamps Index scores were not significant when comparing between groups; however, the Dejour classifications showed higher grades in the recurrent group (P = .013 for A-D grading scale and P = .005 for high/low grading scale). Subgroup analysis revealed that when cartilage damage was present, patients from the primary group had significantly more full-thickness lesions (P < .001) and lower AMADEUS scores (P = .016). Conclusions There was a similarly high prevalence of cartilage injury seen on MRI after both a primary patellar dislocation and a recurrent patellar dislocation. Chondral injury primarily affected the medial and lateral patellar facets and the lateral femoral condyle in both the primary and recurrent dislocation groups. However, the primary group showed an increased number of full-thickness lesions. There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between the primary and recurrent groups. Level of Evidence Level III, retrospective comparative prognostic investigation.
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Affiliation(s)
- Andres R. Perez
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Carlo Coladonato
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Samuel T. Saucedo
- Drexel University College of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - John P. Avendano
- Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
| | - John Corvi
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Mike Campbell
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Steven B. Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
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Perkins CA, Egger AC, Busch MT, Murata A, Willimon SC. Medial Patellofemoral Ligament Reconstruction With or Without Tibial Tubercle Osteotomy in Carefully Selected Patients Results in a 5% Revision Rate: A Preliminary Analysis. J Pediatr Orthop 2024; 44:e144-e150. [PMID: 38031489 DOI: 10.1097/bpo.0000000000002582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE The purpose was to assess the outcomes of medial patellofemoral ligament (MPFL) allograft reconstruction with or without tibial tubercle osteotomy (TTO) in adolescents, with a focus on evaluating demographic and imaging characteristics on outcomes. METHODS A single-institution retrospective study was performed of patients ages 12 to 19 years who underwent MPFL reconstruction +/- TTO for the treatment of lateral patellar instability. Demographic, clinical, surgical, and postoperative information was collected. All x-ray and magnetic resonance imaging measurements were completed independently by 2 surgeons. Patients were contacted to complete patient-reported outcomes at a minimum of 2 years following surgery. The primary outcome measure was recurrent instability resulting in revision surgery. RESULTS Seventy-eight knees in 74 patients, with a median age of 15.3 years (interquartile range: 14.4, 16.1), were included. Forty-five knees underwent isolated MPFL reconstruction and 33 knees had a combined MPFL + TTO. The knees that underwent MPFL + TTO had significantly greater tibial tubercle-trochlear groove distance (19.0 mm vs. 15.4 mm, P =0.015) and patellar tendon-lateral trochlear ridge distance (10.9 mm vs. 5.9 mm, P =0.018) than the knees treated with isolated MPFL reconstruction. Four knees (5.1%) underwent revision stabilization surgery, including 3 knees in the MPFL cohort (6.7%) and 1 knee in the MPFL + TTO cohort (3.0%). The rate of failure between the MPFL and MPFL + TTO knees was not significantly different, P =0.634. There were no differences in age, sex, body mass index, number of dislocations, or any imaging characteristics in patients who underwent revision versus those who did not. Patient-reported outcomes were collected on 50 knees at a median of 36 months (interquartile range: 24, 54) after surgery, and no differences were noted between cohorts. CONCLUSIONS Patellar stabilization surgery, including MPFL reconstruction and TTO in carefully selected patients, had excellent revision-free outcomes in 95% of this adolescent cohort. In this case series, those patients whose treatment included TTO had greater tibial tubercle-trochlear groove and patellar tendon-lateral trochlear ridge as compared to the isolated MPFL cohort. Despite previous literature suggesting demographic and imaging characteristics as risks for recurrent instability, we identified no characteristics within these two distinct surgical treatment groups to be predictive of the need for revision stabilization, regardless of the treatment group. LEVEL OF EVIDENCE Level III-retrospective comparison study.
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Affiliation(s)
- Crystal A Perkins
- Department of Pediatric Orthopedics, Children's Healthcare of Atlanta, Atlanta, GA
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Panagopoulos A, Giannatos V, Antzoulas P, Lakoumentas J, Raoulis V, Hantes M. The 100 Top-Cited Articles on Medial Patellofemoral Ligament: A Bibliometric Analysis and Review. Orthop J Sports Med 2024; 12:23259671231223525. [PMID: 38304053 PMCID: PMC10832438 DOI: 10.1177/23259671231223525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/10/2023] [Indexed: 02/03/2024] Open
Abstract
Background The medial patellofemoral ligament (MPFL) has been investigated widely in the past 30 years, resulting in many research achievements in this field. Purpose To perform a comprehensive bibliometric analysis to evaluate the 100 top-cited articles on the MPFL. Study Design Cross-sectional study. Methods We searched the Scopus database in December 2022 using the terms "medial patellofemoral ligament" OR "MPFL." The search was confined to English-language articles, including technical notes, systematic reviews on clinical outcomes and/or complications, clinical studies, studies regarding complications, and basic science articles (either cadaveric or biomechanical); we excluded letters, case reports, personal opinions, guidelines, editorials, and narrative or other types of reviews. Analysis of the 100 top-cited articles was performed according to total number of citations, average citations per year (ACY), study type, country of origin, journal of publication, affiliated institution, and most published authors. Results The total number of citations was 16,358 (range of citations per article, 72-692). The majority of articles were published as clinical studies (54%), with cadaveric studies being the second most common (21%). Most studies originated in the United States (32%), with Japan (15%) and Germany (13%) following. The American Journal of Sports Medicine published the majority of the 100 top-cited articles (37/100; 6304 citations) as well as the 10 top-cited articles according to ACY (7/10; mean, 285.14 citations). The most prolific authors were Nomura (8 articles); Burks (6 articles); and Inoue, Sillanpää, and Dreyhaupt (5 articles each). Conclusion By analyzing the characteristics of the 100 top-cited articles, this study demonstrated that the MPFL is a growing and popular area of research, with the focus varying through timeline trends. Questions regarding MPFL anatomy, isometry, and biomechanics might have been answered adequately, but research regarding optimal fixation technique under various circumstances is still ongoing.
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Affiliation(s)
| | - Vasileios Giannatos
- Department of Sports Medicine, University Hospital of Patras, Patras, Greece
| | | | - John Lakoumentas
- Department of Medical Physics, University Hospital of Patras, Patras, Greece
| | - Vasileios Raoulis
- Department of Sports Medicine, University Hospital of Larissa, Larissa, Greece
| | - Michael Hantes
- Department of Sports Medicine, University Hospital of Larissa, Larissa, Greece
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18
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Guo H, Zhou K, Sun Z, Feng A, Qin S, Liu L, Sun R, Wang X. Morphological Changes of the Posterior Femoral Condyle After Medial Patellar Retinaculum Plasty in Skeletally Immature Patients With Recurrent Patellar Dislocation and Trochlear Dysplasia. Orthop J Sports Med 2024; 12:23259671231225671. [PMID: 38304055 PMCID: PMC10832434 DOI: 10.1177/23259671231225671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 02/03/2024] Open
Abstract
Background Surgical correction for recurrent patellar dislocation (RPD) can improve femoral trochlear morphology; nonetheless, the effects of surgical correction on femoral condyle morphology are unclear. Purpose To investigate the morphological changes in the posterior femoral condyle in skeletally immature patients with RPD and trochlear dysplasia (TD) after surgical correction. Study Design Cohort study; Level of evidence, 3. Methods A total of 20 skeletally immature patients with bilateral RPD and TD were included in this study. For each patient, the knee that was dislocated more frequently or had sustained a recent injury was treated with medial patellar retinaculum plasty (group S; n = 20 knees), and the asymptomatic or only occasionally dislocated contralateral knee was treated conservatively (group C; n = 20 knees). The lengths of the anterior medial and lateral femoral condyles and the lengths of the posterior medial and lateral femoral condyles were evaluated preoperatively and at the final follow-up. Trochlear morphological characteristics, tibial tuberosity-trochlear groove distance, and patellar tilt angle were compared between preoperative and final follow-up values with the 2-sample paired Student t test and were compared between groups S and C with the independent-samples t test. Results The mean follow-up time was 60.7 ± 4.8 months. No knee in group S experienced a redislocation, whereas 80% (16/20) of knees in group C experienced a dislocation. There were significant group differences in the ratio of the posterior medial femoral condyle (PMFC) to the posterior lateral femoral condyle (PLFC) (group S, 1.08 ± 0.05; group C, 1.14 ± 0.06; P = .042). There was no significant difference in the ratio of the anterior lateral femoral condyle to the anterior medial femoral condyle (group S, 1.16 ± 0.13; group C, 1.18 ± 0.09; P = .635). In group S, all trochlear morphological characteristics and patellofemoral joint characteristics improved compared with preoperatively (P≤ .047 for all). In addition, all values significantly differed between groups S and C at the final follow-up (P≤ .044 for all). Conclusion The study findings demonstrated that the morphology of the posterior femoral condyle in skeletally immature patients with bilateral RPD and TD changes after surgical correction, with the PLFC growing faster than the PMFC.
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Affiliation(s)
- Hailong Guo
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kezhen Zhou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhiwen Sun
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ao Feng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Shiqi Qin
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lei Liu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ran Sun
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaofeng Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Guevel B, Njai A, Raboff A, Hillman A, Barton M, Kocher MS. Does Tibial Tuberosity Osteotomy Improve Outcomes When Combined With Medial Patellofemoral Ligament Reconstruction in the Presence of Increased Tibial Tuberosity-Trochlear Groove Distance? A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671231195905. [PMID: 38107841 PMCID: PMC10722933 DOI: 10.1177/23259671231195905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/19/2023] [Indexed: 12/19/2023] Open
Abstract
Background There has been recent debate regarding the optimal surgical management strategy for recurrent patellofemoral instability in the presence of an increased tibial tuberosity-trochlear groove (TT-TG) distance. In particular, performing a combined tibial tuberosity osteotomy (TTO) and medial patellofemoral ligament reconstruction (MPFLR) for patients with a TT-TG >20 mm has been questioned, with the hypothesis that an isolated MPFLR (iMPFLR) would be just as effective. Purpose To pool and compare outcomes after MPFLR+TTO versus iMPFLR in patients with a TT-TG >20 mm. Study Design Systematic review; Level of evidence, 4. Methods PubMed-MEDLINE, Embase, Web of Science, and Cochrane Central were searched, and a systematic review was performed. Included were studies that reported postoperative redislocation rates and/or functional outcome scores for patients with recurrent patellar instability and a TT-TG >20 mm who underwent either MPFLR+TTO or iMPFLR and had minimum 2-year follow-up data. Methodologic quality was assessed using the modified Coleman Methodology Score (mCMS). A proportional meta-analysis comparing redislocation, subjective instability, and total complication rates was performed, and mean postoperative functional outcome scores were pooled using a random-effects model with a restricted maximum likelihood estimator. Results In total, 1548 studies were screened, from which 13 were included for analysis. Of the 386 included patients (406 knees), 276 underwent MPFLR+TTO and 110 underwent iMPFLR. The mean mCMS was 61.3 ± 10.5 (range, 48-77). The pooled postoperative redislocation rate was 1.22% (95% CI, 0.22%-7%), with no significant difference between the study groups (P = .9995). The pooled complication rate was 10.17% (95% CI, 6.2%-16.3%) with no difference between groups (P = .9275), although the MPFLR+TTO group had higher heterogeneity in complication rates (I2 = 79.4%) compared with iMPFLR (I2 = 0%). There was no group difference in the pooled postoperative Lysholm scores (P = .5177), but patients who underwent iMPFLR had significantly higher postoperative Kujala scores compared with those who underwent MPFLR+TTO (P = .0283). Conclusion Even in the presence of previously indicative anatomic factors (TT-TG >20 mm), TTO combined with MPFLR does not seem to confer additional benefit compared with iMPFLR. This finding could be advantageous in minimizing the burden of additional surgery with its associated risks. The study findings should, however, be interpreted with caution given the heterogeneity of the studies.
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Affiliation(s)
- Borna Guevel
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Abdoulie Njai
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Aly Raboff
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Andrew Hillman
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Michael Barton
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Mininder S. Kocher
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Walla N, Moore T, Harangody S, Fitzpatrick S, Flanigan DC, Duerr RA, Siston R, Magnussen RA. Qualitative visual assessment of the J-sign demonstrates high inter-rater reliability. J ISAKOS 2023; 8:420-424. [PMID: 37499874 DOI: 10.1016/j.jisako.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES To assess the inter- and intra-rater reliability of the classification of the J-sign as "large" versus "small or none" as compared to another two-level system ("present" versus "absent") and a three-level system ("large," "small," or "none") and to identify anatomical and patient factors associated with the presence of a large J-sign. METHODS Forty patients (40 knees) with recurrent patellar instability were prospectively enrolled and recorded on video actively extending their knee while seating. Four raters classified patellar tracking on two separate occasions using three systems: 1) two groups: J-sign versus no J-sign; 2) three groups: large J-sign, small J-sign, or no J-sign; and 3) two groups: large J-sign versus small or no J-sign. The intra- and inter-rater reliability of each system was assessed using kappa statistics. Anatomical (trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patellar height) and patient (Beighton score) factors as well as Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were compared between patients with a large J-sign and patients with a small or no J-sign. RESULTS Inter- and intra-rater reliability were found to be highest with the two-level classification system of a large J-sign versus a small or no J-sign (inter-rater kappa = 0.76, intra-rater kappa = 0.75). Patients with a large J-sign had more severe trochlear dysplasia as assessed with the sulcus angle (p = 0.042) and were more likely to have a tight lateral retinaculum (p = 0.032) and an elevated Beighton score (p = 0.009). No significant differences in KOOS subscales were noted based on the presence of a large J-sign versus a small J-sign or no J-sign. CONCLUSION Qualitative visual assessment of patellar tracking with the J-sign demonstrates substantial inter- and intra-rater reliability, particularly when utilizing a two-group classification system to identify knees with a large J-sign. Patients with a large J-sign demonstrate an increased incidence of a tight lateral retinaculum, generalized ligamentous laxity, and trochlear dysplasia. LEVEL OF EVIDENCE Level III - cross-sectional study.
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Affiliation(s)
- Nicholas Walla
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Toren Moore
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Sarah Harangody
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Sean Fitzpatrick
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert A Duerr
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert Siston
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA.
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21
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Kalinterakis G, Vlastos I, Gianzina E, Sachinis NP, Yiannakopoulos CK. Medial patellofemoral ligament reconstruction using patella bone tunnel techniques with or without implants. A systematic review of outcomes and complications. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3225-3234. [PMID: 37127815 DOI: 10.1007/s00590-023-03559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE Τhe main goal of this study was to compare the clinical results, including the complication rates and patient-reported outcomes, in patients who underwent surgery for recurrent patellar dislocation using different patellar tunnel fixation techniques. This study compared Medial Patellofemoral Ligament (MPFL) reconstruction implant free techniques against ones that used implants. METHODS The present systematic review was conducted according to the PRISMA guidelines. The literature search was conducted in January 2023. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, severe patellar dysplasia or less than 6 months of follow-up were excluded. MINORS and MCMS scores were used for the assessment of methodological quality. RESULTS Data from 750 procedures were collected, of which 284 used implants to perform the procedure while in 455 an implant-free technique was used. Patient age at the time of surgery ranged from 11 to 60 years while the follow-up time of the studies ranged between 3 and 108 months. Postoperative Kujala (0.3, p = 0.89) and Lysholm (1.2, p = 0.26) scores were better in the implant-free techniques compared to implant-based. A higher rate of recurrent dislocation (OR 0.51; 95% CI 0.10-2.54, p = 0.4), subluxation (OR 0.20; 95% CI 0.40-0.88, p = 0.019) and stiffness (OR 0.76; 95% CI 0.33-1.72, p = 0.55) was noted in the implant-free techniques, while the implant-based techniques displayed increased incidence of patella fractures (OR 3.12; 95% CI 0.77-12.6, p = 0.09), reoperation (OR 1.69; 95% CI 0.78-3.65, p = 0.17) and infection (OR 2.07; 95% CI 0.46-9.32, p = 0.33). CONCLUSION There was no significant difference between the 2 techniques in terms of patient reported outcomes. Regarding complications, MPFL reconstruction using implants demonstrated significant higher rate of patella fractures while the implant free technique showed a greater risk of subluxation.
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Affiliation(s)
- Georgios Kalinterakis
- School of Physical Education and Sport Science, Sports Medicine and Exercise Biology Section, National and Kapodistrian University of Athens, Athens, Greece.
| | - Iakovos Vlastos
- School of Physical Education and Sport Science, Sports Medicine and Exercise Biology Section, National and Kapodistrian University of Athens, Athens, Greece
| | - Elina Gianzina
- School of Physical Education and Sport Science, Sports Medicine and Exercise Biology Section, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Platon Sachinis
- Department of Orthopaedics, George Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos K Yiannakopoulos
- School of Physical Education and Sport Science, Sports Medicine and Exercise Biology Section, National and Kapodistrian University of Athens, Athens, Greece
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22
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Hurley ET, Hughes AJ, Savage-Elliott I, Dejour D, Campbell KA, Mulcahey MK, Wittstein JR, Jazrawi LM, Alaia MJ, Arendt EA, Ayeni OR, Bassett AJ, Bonner KF, Camp CL, Carter CW, Chahla J, Ciccotti MG, Cosgarea AJ, Edgar CM, Erickson BJ, Espregueira-Mendes J, Farr J, Farrow LD, Frank RM, Freedman KB, Fulkerson JP, Getgood A, Gomoll AH, Grant JA, Gursoy S, Gwathmey FW, Haddad FS, Hiemstra LA, Hinckel BB, Koh JL, Krych AJ, LaPrade RF, Li ZI, Logan CA, Gonzalez-Lomas G, Mannino BJ, Lind M, Matache BA, Matzkin E, McCarthy TF, Mandelbaum B, Musahl V, Neyret P, Nuelle CW, Oussedik S, Pace JL, Verdonk P, Rodeo SA, Rowan FE, Salzler MJ, Schottel PC, Shannon FJ, Sheean AJ, Sherman SL, Strickland SM, Tanaka MJ, Waterman BR, Zacchilli M, Zaffagnini S. A modified Delphi consensus statement on patellar instability: part I. Bone Joint J 2023; 105-B:1259-1264. [PMID: 38037678 DOI: 10.1302/0301-620x.105b12.bjj-2023-0109.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. 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 to be unanimous. Results Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - David Dejour
- Orthopaedic Department, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Loyola University, Chicago, Illinois, USA
| | - Jocelyn R Wittstein
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | | | - Christopher L Camp
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Cory M Edgar
- Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | | | - João Espregueira-Mendes
- Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal
| | - Jack Farr
- OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA
| | - Lutul D Farrow
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Andreas H Gomoll
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - John A Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - F W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Jason L Koh
- NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Catherine A Logan
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Brian J Mannino
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Martin Lind
- Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Bogdan A Matache
- Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Bert Mandelbaum
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Sam Oussedik
- University College London Hospitals NHS Foundation Trust, London, UK
| | - J L Pace
- Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium
| | - Scott A Rodeo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Fiachra E Rowan
- Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland
| | - Matthew J Salzler
- Department of Orthopedics, Tufts University School of Medicine, Boston, USA
| | - Patrick C Schottel
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, Burlington, Vermont, USA
| | - Fintan J Shannon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | | | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Tao F, Tao H, Jin L, Gao H, Luo Y, Zhang Z. Isolated medial patellofemoral ligament reconstruction improves static bipedal balance control in young patients with recurrent lateral patellar instability. J Orthop Surg Res 2023; 18:771. [PMID: 37828531 PMCID: PMC10571255 DOI: 10.1186/s13018-023-04272-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/08/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Knee stability can be safely and reliably restored using medial patellofemoral ligament (MPFL) reconstruction, which is widely recognized in patients with recurrent lateral patellar instability. However, the literature regarding its influence on static balance control is limited. Thus, this study aimed to assess the impact of MPFL reconstruction on balance control and determine its functional significance. METHODS The study comprised 26 patients with recurrent lateral patellar instability, scheduled for MPFL reconstruction, and 26 matched healthy controls who underwent double-leg stance static posturographic tests pre- and postoperatively on a vertical force platform. Four test conditions were performed with their eyes open and closed, without and with foam support to evaluate the balance control of all participants. The International Knee Documentation Committee subjective knee form, Lysholm knee scoring scale, Tampa scale for kinesiophobia, and active range of motion of the affected knee were synchronously obtained and assessed. RESULTS More postural sway was observed in patients compared to the healthy controls, 11 ± 5 days preoperatively (p < 0.01). However, 374 ± 23 days postoperatively, postural sway between the patients and control subjects was comparable (p > 0.05). Patients following MPFL reconstruction demonstrated better postural stability (p < 0.01). Significant ameliorations were found in all clinical assessments in the study patients postoperatively (p < 0.01). CONCLUSIONS Patients with recurrent lateral patellar instability have inefficient balance control. Static bipedal balance control can be improved under surface perturbation in these patients one year after isolated MPFL reconstruction that enhances the possibility of normal restoration of postural stability. Structural recovery of the ligament could help restore the sensorimotor efficiency and generate the compensatory and anticipatory balance regulation strategies, thereby improving joint function.
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Affiliation(s)
- Fenghua Tao
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238, Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Hai Tao
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238, Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Lin Jin
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238, Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Haijun Gao
- Department of Emergency, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yue Luo
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238, Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Zheng Zhang
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238, Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China.
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Castagno C, Kneedler S, Fares A, Maier M, Gontre G, Weiss WM. Isolated medial patellofemoral reconstruction outcomes: A systematic review and meta-analysis. Knee 2023; 44:59-71. [PMID: 37531844 DOI: 10.1016/j.knee.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/03/2023] [Accepted: 07/16/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Treatment of patellar instability remains up for debate, and a combination of tibial tubercle osteotomy and medial patellofemoral ligament reconstruction (MPFLr) of the medial patellofemoral ligament (MPFL) has become the mainstay treatment for recurrent lateral patellar dislocation. Due to limited small studies, there remains a variety of surgical techniques still being practiced. The use of MPFL reconstruction, in isolation, has demonstrated promise. PURPOSE The purpose of this systematic review and meta-analysis is to investigate if isolated medial patellofemoral ligament reconstruction (iMPFLr) can safely and efficaciously restore knee stability and to present the patient demographics, surgical techniques, graft choices, clinical outcomes, and complications after iMPFLr for recurrent patellar dislocation (RPD). METHODS A review of the current literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, yielded 299 abstracts. Twenty-seven articles met the inclusion/exclusion criteria accounting for 1200 patients. Data was pooled and analyzed focusing on patient demographics, graft type used, Kujala, International Knee Documentation Committee (IKDC), Lysholm, Tegner, and complications. RESULTS Across all studies the weighted mean age was found to be an average of 24.5 years, BMI was 24.9 kg/m2, follow-up was 47.3 months, as 67% were female, TT-TG distance was 15.3 mm, and Caton Deschamps index 1.11. The pooled effect size difference of pre versus post assessment of Kujala was -2.8, IKDC was -4.5, Lysholm was -6.4, and Tegner was -0.74. The pooled complication rate was found to be 8% across all included studies. A subgroup analysis was also performed, specifically looking at how single bundle, double bundle, gracilis, semitendinosus and knee angle during fixation effect outcome data. CONCLUSION This systematic review and meta-analysis demonstrates that isolated MPFL reconstruction is a safe and effective treatment for recurrent patellar dislocations. Given the efficacy of isolated MPFL reconstruction, future investigations should aim to uncover the exact TT-TG distance, trochlear dysplasia, and patella alta grade for selecting patients to undergo this procedure. Furthermore, more primary research needs to be conducted on this topic due to the overall lack of published data from randomized controlled studies and no broad standardization of outcome measurements. LEVEL OF EVIDENCE (4) Systematic Review and Meta-Analysis.
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Affiliation(s)
- Christopher Castagno
- Texas Tech University Health Science Center, Paul Foster School of Medicine, El Paso, TX, USA.
| | - Sterling Kneedler
- Department of Orthopedic Surgery & Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
| | - Austin Fares
- Orthopedic Surgery and Sports Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - Michael Maier
- Orthopedics and Sports Medicine, Baylor College of Medicine and St. Luke's Medical, Sugar Land, TX, USA
| | - Gil Gontre
- Texas Tech University Health Science Center, Paul Foster School of Medicine, El Paso, TX, USA; Texas Tech University Health Science Center, Department of Orthopedics & Rehabilitation, El Paso, TX, USA
| | - William M Weiss
- Orthopedic Sports Medicine, Arthroscopy, & Extremity Reconstruction; Department of Orthopedic Surgery & Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
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25
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Siegel M, Taghizadeh E, Fuchs A, Maier P, Schmal H, Lange T, Yilmaz T, Meine H, Izadpanah K. [Influence of the quadriceps muscles on the patellofemoral contact in patients with low flexion patellofemoral instability after MPFL reconstruction]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:834-842. [PMID: 37567919 PMCID: PMC10539450 DOI: 10.1007/s00132-023-04413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION MPFL reconstruction represents one of the most important surgical treatment options for recurrent patellar dislocations at low flexion angles associated with low flexion patellofemoral instability. Nevertheless, the role of quadriceps muscles in patients with patellofemoral instability before and after patellofemoral stabilization using MPFL reconstruction has not been fully elucidated. The present study investigates the influence of quadriceps muscles on the patellofemoral contact in patients with low flexion patellofemoral instability (PFI) before and after surgical patellofemoral stabilization using MPFL reconstruction using 3 T MRI datasets in early degrees of flexion (0-30°). METHODS In this prospective cohort study, 15 patients with low flexion PFI before and after MPFL reconstruction and 15 subjects with healthy knee joints were studied using dynamic MRI scans. MRI scans were performed in a custom-made pneumatic knee loading device to determine the patellofemoral cartilage contact area (CCA) with and without quadriceps activation (50 N). Comparative measurements were performed using 3D cartilage and bone meshes in 0-30° knee flexion in the patients with patellofemoral instability preoperatively and postoperatively. RESULTS The preoperative patellofemoral CCA of patients with low flexion PFI was 67.3 ± 47.3 mm2 in 0° flexion, 118.9 ± 56.6 mm2 in 15° flexion, and 267.6 ± 96.1 mm2 in 30° flexion. With activated quadriceps muscles (50 N), the contact area was 72.4 ± 45.9 mm2 in extension, 112.5 ± 54.9 mm2 in 15° flexion, and 286.1 ± 92.7 mm2 in 30° flexion without statistical significance. Postoperatively determined CCA revealed 159.3 ± 51.4 mm2 , 189.6 ± 62.2 mm2 and 347.3 ± 52.1 mm2 in 0°, 15° and 30° flexion. Quadriceps activation with 50 N showed a contact area in extension of 141.0 ± 63.8 mm2, 206.6 ± 67.7 mm2 in 15° flexion, and 353.5 ± 64.6 mm2 in 30° flexion, also without statistical difference compared with unloaded CCAs. Subjects with healthy knee joints showed an increase of 10.3% in CCA at 30° of flexion (p = 0.003). CONCLUSION Although patellofemoral CCA increases significantly after isolated MPFL reconstruction in patients with low flexion patellofemoral instability, there is no significant influence of quadriceps muscles either preoperatively or postoperatively.
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Affiliation(s)
- Markus Siegel
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland.
| | - Elham Taghizadeh
- Institute for Medical Image Computing, Fraunhofer MEVIS, Universitätsallee 29, 28359, Bremen, Deutschland
| | - Andreas Fuchs
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - Philipp Maier
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - Hagen Schmal
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
- Dep. Of Orthopedic Surgery, University Hospital Odense, Sdr. Boulevard 29, 5000, Odense, Dänemark
| | - Thomas Lange
- Division of Medical Physics, Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Killianstraße 5a, 79106, Freiburg, Deutschland
| | - Tayfun Yilmaz
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - Hans Meine
- Institute for Medical Image Computing, Fraunhofer MEVIS, Universitätsallee 29, 28359, Bremen, Deutschland
| | - Kaywan Izadpanah
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
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Nakamura R, Kawashima F, Amemiya M, Shimakawa T, Okano A. Derotational Hybrid Closed-Wedge High Tibial Osteotomy for Knee Osteoarthritis With Patellar Subluxation Caused by Tibial Torsional Deformity. Arthrosc Tech 2023; 12:e1687-e1694. [PMID: 37942092 PMCID: PMC10627868 DOI: 10.1016/j.eats.2023.05.017] [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: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 11/10/2023] Open
Abstract
Patellar subluxation and recurrent dislocation are commonly treated with medial patellofemoral ligament reconstruction, and patients with predisposing factors for these problems often require additional bony realignment procedures. However, these procedures mainly address problems in the axial plane, and patients with medial-compartmental knee osteoarthritis may require further realignment in the coronal plane. In this Technical Note article, we introduce our technique for derotational hybrid closed-wedge high tibial osteotomy. Using this technique, simultaneous 3-dimensional realignment in the axial, coronal, and sagittal planes can be achieved in patients with medial compartmental knee osteoarthritis and patellar subluxation caused by a tibial torsional deformity. The indications for the technique and the preoperative planning assessments involving a static torsional deformity analysis on computed tomography images and a dynamic gait analysis by our walking-on-paper method are presented. This is followed by a detailed description of the surgical procedure, together with consideration of the pearls and pitfalls of the procedure. A video of the surgery performed in a representative case with medial knee osteoarthritis and patellar subluxation in the right knee owing to an outward tibial torsion deformity is also provided.
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Affiliation(s)
- Ryuichi Nakamura
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
| | - Fumiyoshi Kawashima
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Masaki Amemiya
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoyuki Shimakawa
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
- Department of Orthopedic Surgery, Yaese-kai Doujin Hospital, Urasoe, Japan
| | - Akira Okano
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
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Almeida J, Senra AR, Leite MJ, Oliveira P, Sousa A, Torres J. Is combined MPFL reconstruction and tubercule tibial osteotomy superior to isolated reconstruction? A systematic review and meta-analysis. J Clin Orthop Trauma 2023; 45:102277. [PMID: 38044955 PMCID: PMC10689258 DOI: 10.1016/j.jcot.2023.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/18/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose There is no consensus for management of patellar instability, even in the case of malalignment. The purpose of the review is to evaluate outcomes in the literature of MPFL reconstruction with and without tibial tubercle osteotomy. Methods Two databases PubMed and Scopus were searched for studies comparing MPFL reconstruction with and without concomitant tibial tuberosity osteotomy. PRISMA guidelines were followed. Data on functional outcomes via Kujala score, redislocation rates and return to sport rates were reported. Results 9 studies included data from 806 knees: 463 submitted to isolated MPFL reconstruction, and 343 submitted to the combined surgery. Patients submitted to the combined procedure had all TT-TG values superior to 18, while the ones with isolated reconstruction had more heterogeneous values, varying between 13 and 20 mm. 77.78% of the studies reported on postoperative Kujala scores, with a mean value of 83.53 in patients who underwent MPFL reconstruction alone and 83.72 in those who underwent the combined procedure. The mean difference between the two groups was -0.83, with the improvement of the score statistically significant in 22.22% of the studies, regardless of the surgery. Concerning redislocation rate, odds ratio comparing both procedures was 0.84 (p = 0.67). Conclusion The principal finding is that the MPFL reconstruction with or without TTO resulted in similar functional outcomes, assessed by the Kujala score, and low complications concerning recurrent patellar dislocation. More robust literature is needed in the setting of a high TT-TG distance. Level of evidence IV.
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Affiliation(s)
- Joana Almeida
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
| | - Ana Rita Senra
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
| | - Maria João Leite
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
- Porto Medical School, Porto University, Portugal
- Hospital CUF Porto, Portugal
| | - Paulo Oliveira
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
- Porto Medical School, Porto University, Portugal
- Hospital CUF Porto, Portugal
- Head of the Portuguese Society for the Study of Knee Pathology, Portugal
| | - António Sousa
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
- Porto Medical School, Porto University, Portugal
- Hospital CUF Porto, Portugal
| | - João Torres
- Department of Orthopedics and Traumatology, São João University Hospital, Porto, Portugal
- Porto Medical School, Porto University, Portugal
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Li ZI, Triana J, Lott A, Rao N, Jazrawi T, Montgomery SR, Buldo-Licciardi M, Alaia MJ, Strauss EJ, Jazrawi LM, Campbell KA. Patients who undergo bilateral medial patellofemoral ligament reconstruction return to sport at a similar rate as those that undergo unilateral reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:4195-4203. [PMID: 37219546 DOI: 10.1007/s00167-023-07462-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA.
| | - Jairo Triana
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Ariana Lott
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Naina Rao
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Taylor Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Samuel R Montgomery
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Michael Buldo-Licciardi
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
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Elias JJ, Cosgarea AJ, Tanaka MJ. Adding Tibial Tuberosity Medialization to Medial Patellofemoral Ligament Reconstruction Reduces Lateral Patellar Maltracking During Multidirectional Motion in a Computational Simulation Model. Arthrosc Sports Med Rehabil 2023; 5:100753. [PMID: 37645404 PMCID: PMC10461214 DOI: 10.1016/j.asmr.2023.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/29/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To determine whether adding tibial tuberosity medialization to medial patellofemoral ligament (MPFL) reconstruction reduces lateral patellar maltracking during a dynamic multidirectional activity and to investigate when medial patellofemoral contact pressures are elevated during daily activities, such as squatting. Methods Seven computational models representing knees with patellar instability, including lateral patellar maltracking, were evaluated following simulated MPFL reconstruction (bisect offset index > .75). Tibial tuberosity medialization was added to MPFL reconstruction for each model. Patellar tracking during multidirectional motion was evaluated by simulating pivot landing. Analysis of pivoting focused on early flexion (5° to 40°). Patellofemoral contact pressures during daily function were evaluated by simulating knee squatting. Data were analyzed with paired comparisons between MPFL reconstruction with and without tuberosity medialization. Results The patella dislocated during pivoting for 2 models with an isolated MPFL reconstruction and for 1 model including tibial tuberosity medialization. Adding tibial tuberosity medialization to MPFL reconstruction significantly decreased bisect offset index by ∼0.1 from 5° to 40° (P < .03). For knee squatting, medializing the tibial tuberosity significantly increased maximum medial contract pressure by ∼0.5 MPa from 30° to 85° (P < .05) but did not significantly influence maximum lateral pressure. Conclusions In this study of simulated multidirectional motion, MPFL reconstruction did not sufficiently constrain the patella for some knees. Adding tibial tuberosity medialization to MPFL reconstruction in these models reduced lateral patellar maltracking during multidirectional motion but increased pressure applied to medial cartilage during squatting. Clinical Relevance After establishing the influence of tibial tuberosity medialization on patellar maltracking for an idealized population, as was done in the current study, future simulation studies can be performed to better determine the anatomical characteristics of patients for whom tibial tuberosity medialization is needed to reduce the risk of postoperative patellar maltracking.
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Affiliation(s)
- John J. Elias
- Department of Health Sciences, Cleveland Clinic Akron General, Cleveland, Ohio, U.S.A
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Shankar DS, Avila A, DeClouette B, Vasavada KD, Jazrawi IB, Alaia MJ, Gonzalez-Lomas G, Strauss EJ, Campbell KA. Home ownership, full-time employment, and other markers of higher socioeconomic status are predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction. Knee Surg Relat Res 2023; 35:20. [PMID: 37461119 DOI: 10.1186/s43019-023-00193-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 06/29/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR). METHODS We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection. RESULTS Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (β = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (β = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (β = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (β = 8.7 [0.9, 16.5], p = 0.03). CONCLUSION Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Dhruv S Shankar
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA.
| | - Amanda Avila
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Brittany DeClouette
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Kinjal D Vasavada
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Isabella B Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38Th St, 4Th Floor, New York, NY, 10016, USA
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Leite CBG, Hinckel BB, Ribeiro GF, Giglio PN, Santos TP, Bonadio MB, Arendt E, Gobbi RG. Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. J ISAKOS 2023; 8:189-196. [PMID: 36924824 DOI: 10.1016/j.jisako.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/29/2023] [Accepted: 02/25/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVES To report outcomes and re-dislocation rates of medial patellar stabilizers reconstruction without bone procedures for correction of anatomical risk factors for patellar instability in skeletally immature patients; to compare isolated medial patellofemoral ligament (MPFL) reconstruction to combined MPFL and medial patellotibial ligament (MPTL) reconstruction in this population. METHODS Patients with open physis and bone abnormalities including patella alta and/or increased tibial tubercle-trochlear groove (TT-TG) distance and/or trochlear dysplasia underwent MPFL reconstruction, either isolated or associated with MPTL reconstruction. Preoperative, 1-year follow-up and the latest follow-up (5 years minimum) data were collected. Radiological and clinical evaluations were conducted, with special attention to failure rate. Comparison of results from isolated MPFL and combined MPFL/MPTL reconstructions was performed. RESULTS Twenty-nine patients were included, 19 in the isolated MPFL group (median 14 years old; follow-up 5.8 ± 1.7 years) and 10 in the combined MPFL/MPTL group (median 13.5 years old; follow-up 5.2 ± 1.4 years). Kujala and Tegner scores increased over time, although without statistically significant differences between the two groups at the latest follow-up (p = 0.840 and p > 0.999, respectively). During follow-up, 5 of 19 (26.3%) isolated MPFL and 2 of 10 (20%) MPFL/MPTL reconstructions experienced recurrence of patellar dislocation (p > 0.999). Trochlear dysplasia type D (p = 0.028), knee rotation (p = 0.009) and lateral patellar tilt angle (p = 0.003) were associated with patellar instability recurrence. The isolated MPFL group showed increased laxity on physical exam at the latest follow-up compared to the 1-year follow-up (patellar glide test (p = 0.002), patellar tilt test (p = 0.042) and subluxation in extension (p = 0.019). This increased laxity was not observed in the MPFL/MPTL group (p > 0.999). Comparing both groups, the glide test was significantly better in the combined MPFL/MPTL group in comparison to the isolated MPFL reconstruction group at the latest follow-up (p = 0.021). CONCLUSION MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. Addition of a MPTL reconstruction to the MPFL may result in decreased patellar laxity on physical exams, as demonstrated by better patellar glide test, patellar tilt test and subluxation in extension. LEVEL OF EVIDENCE Level III; retrospective cohort study.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Betina Bremer Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI 48180, USA.
| | - Gabriel Fernandes Ribeiro
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Tarsis Padula Santos
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Elizabeth Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
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Heindel K, Smoak J, Kocan J, Cossell C, Haider MN, Levy BJ, Bisson L. Stiffness and Instability After MPFL Reconstruction Using a Fluoroscopic Versus Open Technique to Localize the Femoral Attachment Site: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671221148482. [PMID: 37342554 PMCID: PMC10278418 DOI: 10.1177/23259671221148482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 06/23/2023] Open
Abstract
Background Open and fluoroscopic techniques have been described for localization of the femoral attachment site in medial patellofemoral ligament (MPFL) reconstruction. No study to date has evaluated if one technique is superior to another in terms of complications. Purpose To review the literature comparing clinical outcomes of MPFL reconstruction using the fluoroscopic versus open technique to localize the site of femoral graft placement. Study Design Systematic review; Level of evidence, 4. Methods A systematic literature review was performed via PubMed, Embase, and CINAHL to identify articles published between the inception of these databases and March 1, 2022, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. This search yielded 4183 publications for initial review. Studies with at least a 2-year follow-up and complete reporting of patient-reported outcomes, range of motion, recurrent instability, and/or complications (ie, stiffness, infection, persistent pain) were included. We excluded studies of patients with collagen disorders; revision surgeries; surgeries with concomitant procedures; synthetic MPFL reconstruction; MPFL repairs; combined open and radiographic technique; and case series that included <10 patients. A proportional meta-analysis was performed by calculating the pooled estimate of incidence with 95% CIs using a fixed-effects model with double arcsine transformation (Freeman-Tukey) for each type of surgical technique (fluoroscopic or open). Results A total of 29 studies met our inclusion criteria, of which 15 studies (566 patients) used the open technique and 14 studies (620 patients) used fluoroscopy. There were no significant differences between the open and fluoroscopic techniques in the incidence of postoperative apprehension (P = .4826), postoperative subjective instability (P = .1095), postoperative objective instability (P = .5583), reoperations (P = .7981), recurrent dislocation (P = .6690), or arthrofibrosis (P = .8118). Conclusion Both open and radiographic localization of the femoral graft position in MPFL reconstruction offer similar outcomes and rates of complications.
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Affiliation(s)
- Koan Heindel
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Jason Smoak
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Joseph Kocan
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Charles Cossell
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Mohammad Nadir Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Benjamin J. Levy
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Leslie Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA
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Siegel M, Taghizadeh E, Lange T, Fuchs A, Yilmaz T, Maier P, Meine H, Schmal H, Izadpanah K. Influence of Medial Patellofemoral Ligament Reconstruction on Patellofemoral Contact in Patients With Low-Flexion Patellar Instability: An MRI Study. Orthop J Sports Med 2023; 11:23259671231160215. [PMID: 37213660 PMCID: PMC10192662 DOI: 10.1177/23259671231160215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/19/2023] [Indexed: 05/23/2023] Open
Abstract
Background Medial patellofemoral ligament (MPFL) reconstruction is a well-established procedure for the treatment of patients with patellofemoral instability (PFI) at low flexion angles (0°-30°). Little is known about the effect of MPFL surgery on patellofemoral cartilage contact area (CCA) during the first 30° of knee flexion. Purpose/Hypothesis The purpose of this study was to investigate the effect of MPFL reconstruction on CCA using magnetic resonance imaging (MRI). We hypothesized that patients with PFI would have a lower CCA than patients with healthy knees and that CCA would increase after MPFL reconstruction over the course of low knee flexion. Study Design Cohort study; Level of evidence, 2. Methods In a prospective matched-paired cohort study, the CCA of 13 patients with low-flexion PFI was determined before and after MPFL reconstruction, and the data were compared with those of 13 healthy volunteers (controls). MRI was performed with the knee at 0°, 15°, and 30° of flexion in a custom-designed knee-positioning device. To suppress motion artifacts, motion correction was performed using a Moiré Phase Tracking system via a tracking marker attached to the patella. The CCA was calculated on the basis of semiautomatic cartilage and bone segmentation and registration. Results The CCA (mean ± SD) at 0°, 15°, and 30° of flexion for the control participants was 1.38 ± 0.62, 1.91 ± 0.98, and 3.68 ± 0.92 cm2, respectively. In patients with PFI, the CCA at 0°, 15°, and 30° of flexion was 0.77 ± 0.49, 1.26 ± 0.60, and 2.89 ± 0.89 cm2 preoperatively and 1.65 ± 0.55, 1.97 ± 0.68, and 3.52 ± 0.57 cm2 postoperatively. Patients with PFI exhibited a significantly reduced preoperative CCA at all 3 flexion angles when compared with controls (P ≤ .045 for all). Postoperatively, there was a significant increase in CCA at 0° of flexion (P = .001), 15° of flexion (P = .019) and 30° of flexion (P = .026). There were no significant postoperative differences in CCA between patients with PFI and controls at any flexion angle. Conclusion Patients with low-flexion patellar instability showed a significant reduction in patellofemoral CCA at 0°, 15°, and 30° of flexion. MPFL reconstruction increased the contact area significantly at all angles.
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Affiliation(s)
- Markus Siegel
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
- Markus Siegel, MD,
Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital,
Albert Ludwigs University Freiburg, Hugstetter Strasse 55, Freiburg, 79098
Germany ()
| | - Elham Taghizadeh
- Fraunhofer Institute for Digital
Medicine MEVIS, Bremen, Germany
| | - Thomas Lange
- Division of Medical Physics, Department
of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg,
Faculty of Medicine, Albert Ludwigs University of Freiburg, Freiburg, Germany
| | - Andreas Fuchs
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
| | - Tayfun Yilmaz
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
| | - Philipp Maier
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
| | - Hans Meine
- Fraunhofer Institute for Digital
Medicine MEVIS, Bremen, Germany
| | - Hagen Schmal
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
- Department of Orthopedic Surgery,
University Hospital Odense, Odense, Denmark
| | - Kaywan Izadpanah
- Department of Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Albert Ludwigs University of Freiburg,
Freiburg, Germany
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Duke AJ, Dai A, Botros D, Leatherwood W, Montemurro NJ, Richardson M, Grossman M. A Patella-Sided Tensioning Technique for Medial Patellofemoral Ligament Reconstruction. Arthrosc Tech 2023; 12:e483-e489. [PMID: 37138696 PMCID: PMC10149653 DOI: 10.1016/j.eats.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/24/2022] [Indexed: 05/05/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) is a common procedure for treatment of recurrent patellofemoral instability. Over the last two decades, multiple surgical techniques for MPFL reconstruction have been described with no clear consensus on a superior reconstruction technique. Appropriate graft tensioning is one of the most important factors for a successful MPFL reconstruction. Overtensioning of the MPFL graft can lead to patellofemoral joint overload and undertensioning can lead to recurrent instability. Current literature demonstrates descriptions of MPFL reconstruction with final graft tensioning performed off of the femoral side. We describe a technique in this article for performing final graft tensioning from the patellar side, which gives the surgeon an option for intraoperative tension adjustments after evaluating patellar tracking.
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Affiliation(s)
- Alexander J. Duke
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
- Address correspondence to Alexander J. Duke, M.D., Stony Brook University Hospital, Department of Orthopaedic Surgery, 101 Nicolls Rd., HSC T-18, Room 089, Stony Brook, NY, 11794, U.S.A.
| | - Amos Dai
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
| | - Daniel Botros
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
| | - William Leatherwood
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
| | - Nicholas J. Montemurro
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
| | - Meghan Richardson
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York, U.S.A
| | - Mark Grossman
- Department of Orthopaedic Surgery, NYU-Langone Winthrop Hospital, Mineola, New York, U.S.A
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Zimmermann F, Milinkovic DD, Zimmerer A, Balcarek P. When Should Bony Correction Be Considered in Addition to Medial Patellofemoral Ligament Reconstruction? Results of a Clinically Derived 2-Group Classification of Lateral Patellar Instability Based on 122 Patients at 2- to 5-Year Follow-up. Orthop J Sports Med 2023; 11:23259671221147572. [PMID: 36743734 PMCID: PMC9893382 DOI: 10.1177/23259671221147572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/21/2022] [Indexed: 01/29/2023] Open
Abstract
Background The need for concomitant bony procedures to realign pathoanatomic risk factors in addition to medial patellofemoral ligament reconstruction (MPFL-R) remains unclear. Purpose To evaluate a clinically derived 2-part classification of lateral patellar instability aimed at identifying patients indicated for a concomitant bony procedure. Study Design Cohort study; Level of evidence, 3. Methods The study included 122 patients (42 male, 80 female; mean ± SD age, 22 ± 6 years) who were assigned to a mild instability group (mIG) and a complex instability group (cIG) based on the reversed dynamic patellar apprehension test (ReDPAT) and J-sign. The mIG had a positive ReDPAT result <40° to 50° of knee flexion and an absent or low-grade J-sign (grade 1), and the cIG had a positive ReDPAT result >40° of knee flexion and/or a high-grade J-sign (grade 2 or 3). The mIG underwent isolated MPFL-R, and the cIG underwent MPFL-R and concomitant bony procedures depending on the established risk factor assessment. For evaluation, the BANFF Patellar Instability Instrument 2.0 (BPII 2.0) and numeric analog scale (0-10) for patellofemoral pain and subjective knee function were used. The minimal clinically important difference for the BPII 2.0 was ascertained by calculating half the standard deviation of baseline scores. Results Radiographic analysis confirmed a significantly more pronounced pathoanatomic risk factor constellation in the cIG regarding severity of trochlear dysplasia, distal malalignment, and patellar height (all P < .05). At final follow-up, no patellar redislocation occurred in either group; 2 patients in the cIG reported patellar subluxation. Within both groups, all outcome scores improved significantly pre- to postoperatively (all P < .0001); no between-group difference was found regarding BPII 2.0 score and numeric analog scale for function. The minimal clinically important difference for the BPII 2.0 was met by 84% (32/38) of the mIG and 90% (76/84) of the cIG (P = .36), but the cIG experienced more patellofemoral pain than the mIG (1.3 ± 1.6 vs 2.1 ± 2.1; P = .036). Conclusion Patients with a high-grade J-sign and/or a positive ReDPAT finding beyond 40° to 50° of knee flexion exhibited a significantly more pronounced pathoanatomic risk factor constellation; however, the correction of modifiable risk factors led to similarly good outcomes to patients who underwent isolated MPFL-R. A slightly higher level of patellofemoral pain after bony procedures was evident in these patients.
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Affiliation(s)
| | | | | | - Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany.,Department of Trauma Surgery, Orthopaedics and Plastic Surgery,
University of Göttingen, Göttingen, Germany.,Peter Balcarek, MD, Arcus Sportklinik, 75179 Pforzheim, Germany
()
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The remaining parameters of patellar instability could be affected for osteoarthritic change after medial patellofemoral ligament reconstruction with or without anteromedialization of the tibial tubercle osteotomy for patellar instability: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:56. [PMID: 36683021 PMCID: PMC9869604 DOI: 10.1186/s12891-022-06100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 12/19/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In literature, studies evaluating the factors associated the postoperative progression of patellofemoral (PF) osteoarthritis (OA) following patellar stabilization surgery are limited. This study aimed to compare the clinical outcomes after medial patellofemoral ligament reconstruction (MPFLR) as an isolated procedure (iMPFLR) and in combination with anteromedialization (AMZ) of the tibial tubercle osteotomy (TTO) and investigate the factors related to the postoperative progression of PFOA after patellar stabilization surgery. METHODS Between 2009 and 2020, 30 knees of 23 consecutive patients underwent MPFLR with or without AMZ, using an autologous semitendinosus tendon graft; they were followed up for more than 2 years in the retrospective nature of the study. iMPFLR was performed in cases of recurrent patellar dislocation with normal tibial tubercle-trochlear groove (TT-TG) distance and no PFOA, and MPFLR+AMZ was performed for cases of excessive TT-TG distance, preoperative PFOA of recurrent patellar dislocation, or habitual patellar dislocation. Clinical findings and radiographs of the PF joint were evaluated pre- and postoperatively with PF alignment parameters and PFOA and were compared between surgical procedures. Factors for the postoperative progression of PFOA were compared between the OA progression and non-progression groups. RESULTS Postoperative clinical score, radiographic parameters except for sulcus angle, TT-TG distance, and progression of PFOA were not significantly different between the iMPFLR and MPFLR+AMZ groups. Postoperative lateral patellar displacement (p = 0.001) and congruence angle (p = 0.017) were significantly different between the OA progression and non-progression groups. CONCLUSION Similar to MPFLR for recurrent cases, MPFLR with AMZ can improve the clinical and radiographic outcomes in severe cases. The remaining parameters of patellar instability could be affected in the postoperative progression of PFOA after MPFL reconstruction with or without AMZ of TTO for patellar instability.
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Hu F, Shi W, Wang H, Wang C. A Novel Technique of Arthroscopic Femoral Tunnel Placement during Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation. J Clin Med 2023; 12:jcm12020680. [PMID: 36675609 PMCID: PMC9860788 DOI: 10.3390/jcm12020680] [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: 11/21/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Recurrent patellar dislocation is a commonly encountered patellofemoral disease. Prompt surgical intervention is indicated for recurrent dislocation to restore patellofemoral stability. As one of the most preferred procedures, medial patellofemoral ligament (MPFL) reconstruction has been implemented on a large scale. Femoral tunnel placement remains a crucial technical issue during MPFL reconstruction and is critical to ensure the isometry and proper tension of the graft. Currently, visual-palpatory anatomic landmarks and fluoroscopy-guided radiographic landmarks comprise the main approaches to intraoperative femoral tunnel positioning. However, the accuracy of both methods has been questioned. This article introduces an arthroscopic femoral tunnel placement technique. Apart from traditional anteromedial and anterolateral portals, two auxiliary arthroscopic portals are specially designed. The adductor tubercle, the medial epicondyle and the posterior edge are selected as main anatomic landmarks and are directly visualized in sequence under arthroscope. The relative position between the femoral attachment of the MPFL and the three landmarks is measured on preoperative three-dimensional computed tomography, providing semi-quantified reference for intraoperative localization. This technique achieves minimally invasive tunnel placement without X-ray exposure, and especially suits obese patients for whom palpatory methods are difficult to perform.
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Sherman SL, Rund JM, Welsh JW, Ray T, Worley JR, Oladeji LO, Gray AD, Hinckel BB. Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes. Arthrosc Sports Med Rehabil 2023; 5:e257-e262. [PMID: 36866317 PMCID: PMC9971998 DOI: 10.1016/j.asmr.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Seth L. Sherman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A.,Address correspondence to Seth L. Sherman, M.D., 450 Broadway Pavilion A, Redwood City, CA 94063, U.S.A.
| | - Joseph M. Rund
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - John W. Welsh
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Taylor Ray
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A
| | - John R. Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Aaron D. Gray
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Betina B. Hinckel
- Oakland University, Rochester, Michigan, U.S.A.,Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, U.S.A
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Soft-tissue fixation is not inferior to suture-anchor fixation in reconstruction of the medial patellofemoral ligament using a nonresorbable suture tape. Knee Surg Sports Traumatol Arthrosc 2023; 31:292-298. [PMID: 35994076 DOI: 10.1007/s00167-022-07120-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Reconstruction of the medial patellofemoral ligament (MPFL-R) with nonresorbable suture tape (FiberTape®, FT) is becoming popular. Patella-side fixation of the FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate whether patella-side soft-tissue fixation can achieve equivalent primary stability compared to suture-anchor fixation. METHODS In ten human, fresh-frozen knee joint specimens (m/f 6/4; age 74 ± 9 a), the MPFL was identified and dissected near the femoral insertion site. In five knee joints, the MPFL-R using FT was performed with soft-tissue fixation at the patella (study group; SG), and in five knee joints, the FT was fixed via suture anchors (control group, CG). All reconstructions were evaluated until load to failure of the patella-side fixation with a displacement rate of 200 mm/min. RESULTS The mean maximum load to failure in the SG was 395.3 ± 57.9 N. All reconstructions failed by complete tearing off the medial patellar retinaculum from its medial patellar margin, but fixation of the FT remained stable. In the CG, the mean maximum load to failure was 239.4 ± 54.5 N and was significantly different compared to the SG (p = 0.04). All reconstructions failed via pullout of the suture anchors. Stiffness and elongation did not differ between the groups, and no failure of the FT was observed in any of the specimens. CONCLUSION Primary stability of soft-tissue MPFL-R using FT was superior to suture-anchor fixation. Both fixation techniques provided sufficient primary stability, superior to previously reported native MPFL tensile strengths. MPFL-R with FT could be a possible alternative procedure for MPFL-R, eliminating potential complications due to autologous tendon graft harvesting.
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Milinkovic DD, Zimmermann F, Balcarek P. Medial patellofemoral ligament reconstruction using nonresorbable sutures yields comparable outcomes to reconstruction with a pedicled quadriceps tendon autograft when performed in addition to bony risk factor correction. Knee Surg Sports Traumatol Arthrosc 2023; 31:264-271. [PMID: 35972519 PMCID: PMC9859873 DOI: 10.1007/s00167-022-07104-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the results for reconstruction of the medial patellofemoral ligament using synthetic nonresorbable sutures (S-MPFL-R) in comparison to MPFL-R using quadriceps tendon autograft (QT-MPFL-R) in patients undergoing simultaneous correction of anatomic risk factors for lateral patellar instability (LPI) at a minimum of 2 years of follow-up. METHODS Between November 2018 and June 2019, 19 patients (male/female 8/11; mean age 26 ± 7 years) underwent S-MPFL-R (FiberTape®) in combination with the correction of predisposing risk factors for LPI. The control group of 38 patients (male/female 16/22, mean age 26 ± 6 years) who underwent QT-MPFL-R was matched 1:2 by sex, age, anatomic risk factors, and concomitant surgical correction of bony risk factors. The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analog scale (NAS 0-10) for patellofemoral pain and subjective knee joint function were used to assess patients' reported quality of life before and after surgery. RESULTS The BPII 2.0 score increased from 35.0 ± 21.7 points to 79.7 ± 13.3 points (p < 0.0001) in the S-MPRL-R group and from 44.3 ± 19.6 points to 80.9 ± 15 points (p < 0.0001) in the QT-MPFL-R group from preoperatively to postoperatively, respectively, without any significant difference between the groups. In the S-MPFL-R group and QT-MPFL-R group, 95% (18/19) and 92% (35/38) of patients, respectively, crossed the minimally clinically important difference reported for the BPII 2.0. NAS values for pain and subjective knee joint function improved significantly in both groups (p < 0.0001, p < 0.0001) without any significant difference between the groups at the final follow-up. CONCLUSIONS This study demonstrates that nonresorbable sutures can serve as a viable option for MPFL-R, yielding comparable outcomes compared to quadriceps tendon autograft reconstruction when performed concomitantly with the correction of anatomic risk factors for LPI. This option reduces the need for autologous tendon harvesting or the use of allografts for MPFL-R. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Danko Dan Milinkovic
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Luisenstrasse 64, 10117, Berlin, Germany.
| | - Felix Zimmermann
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany ,Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, University Medicine Göttingen, Göttingen, Germany
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Popescu D, Pomenta MV, Simion C, Neculau DC, Popescu IA. Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon Femoral Ligament in Skeletally Immature Patients. Arthrosc Tech 2022; 12:e59-e64. [PMID: 36814983 PMCID: PMC9939610 DOI: 10.1016/j.eats.2022.08.058] [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: 07/18/2022] [Accepted: 08/26/2022] [Indexed: 12/24/2022] Open
Abstract
The medial patellofemoral ligament (MPFL) reconstruction is challenging in skeletally immature patients due to the anatomical particularities at this age. Recently, the medial quadriceps tendon femoral ligament (MQTFL) has received great interest for its ability to restrain the patella's instability along with MPFL. No gold-standard technique has been described so far to reconstruct both MPFL and MQTFL in skeletally immature patients. We present a technique to safely reconstruct the MPFL and the MQTFL in children and adolescents. The gracilis tendon autograft is harvested and passed through the medial collateral ligament as a pulley. The free ends of the graft are passed through the patella by an "L-shaped tunnel" and tied to itself. The other free end of the graft is pulled through the medial third of the quadriceps tendon and tied to itself to achieve tension. Our technique is reproducible, implant-free and avoids complications associated with femoral drilling and graft fixation. However no long-term follow-up results are available.
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Affiliation(s)
- Dragos Popescu
- Ortopedicum - Orthopaedic Surgery & Sports Clinic, Bucharest, Romania,Knee Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Maria Victoria Pomenta
- Ortopedicum - Orthopaedic Surgery & Sports Clinic, Bucharest, Romania,Arthroscopy Unit. Catalunya General University Hospital, Spain
| | - Cosmin Simion
- Ortopedicum - Orthopaedic Surgery & Sports Clinic, Bucharest, Romania,Marie Curie Children’s Clinical Hospital, Bucharest, Romania,University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
| | - Diana-Cosmina Neculau
- Ortopedicum - Orthopaedic Surgery & Sports Clinic, Bucharest, Romania,University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
| | - Ion-Andrei Popescu
- Ortopedicum - Orthopaedic Surgery & Sports Clinic, Bucharest, Romania,Address correspondence to Ion-Andrei Popescu, Ortopedicum - Orthopaedic Surgery & Sports Clinic, Str. Banul Antonache nr. 51, Bucharest, Romania.
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Long J, Pappa N, Stitgen M, Flanigan DC, Fowler B, DiBartola AC, Magnussen RA. Patient-Reported Outcomes Following Medial Patellofemoral Reconstruction With Peroneus Longus Allografts Demonstrate Good Results. Arthrosc Sports Med Rehabil 2022; 5:e201-e206. [PMID: 36866312 PMCID: PMC9971893 DOI: 10.1016/j.asmr.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To evaluate the recurrent dislocation risk and patient-reported outcomes of peroneus longus allograft tissue for medial patellofemoral ligament (MPFL) reconstruction. Methods Patients who underwent MPFL reconstruction with peroneus longus allograft at an academic center between 2008 and 2016 were identified. Record review and patient contact were used to identify any cases of recurrent patellar dislocation and collect patient-reported outcomes scores (Knee injury and Osteoarthritis Outcome Score [KOOS], Norwich Patellar Instability score, Marx activity scale). Patients with 1-year minimum follow-up were included. Outcomes were quantified and the proportion of patients reaching a previously defined patient acceptable symptom state (PASS) for patellar instability was determined. Results Sixty-one patients (42 female and 19 male) underwent MPFL reconstruction with peroneus longus allograft during the study period. Forty-six patients (76%) with 1-year minimum follow up were contacted at a mean of 3.5 years postoperative. The mean age at time of surgery was 22 ± 7.2 years. Patient-reported outcomes data were available in 34 patients. Mean KOOS subscale scores were as follows: Symptoms 83.2 ± 19.1, Pain 85.2 ± 17.6, Activities of Daily Living 89.9 ± 14.8, Sports 75 ± 26.2, and Quality of Life 72.6 ± 25.7. The mean Norwich Patellar Instability score was 14.9% ± 17.4%. The mean Marx activity score was 6.0 ± 5.2. No recurrent dislocations were noted during the study period. Sixty-three percent of patients who underwent isolated MPFL reconstruction met PASS thresholds in at least 4 of 5 KOOS subscales. Conclusions The use of a peroneus longus allograft in MPFL reconstruction in conjunction with other indicated procedures results in a low re-dislocation risk and a high proportion of patients meeting PASS criteria for patient-reported outcome scores 3 to 4 years postoperatively. Level of Evidence IV, case series.
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Affiliation(s)
| | | | | | | | | | | | - Robert A. Magnussen
- Address correspondence to Robert A. Magnussen, M.D., Sports Medicine Research Institute, 2835 Fred Taylor Dr., Columbus, OH, 43202.
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Migliorini F, Maffulli N, Bell A, Betsch M. Outcomes, Return to Sport, and Failures of MPFL Reconstruction Using Autografts in Children and Adolescents with Recurrent Patellofemoral Instability: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121892. [PMID: 36553335 PMCID: PMC9777394 DOI: 10.3390/children9121892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION This study systematically reviews and updates the current evidence on the outcomes of medial patellofemoral ligament (MPFL) reconstruction using autografts in children and adolescents with recurrent patellofemoral instability. The outcomes of interest were improvements in patient reported outcomes measures (PROMs), return to sport rates, and the rates of surgical failure. METHODS This systematic review was performed according to the 2020 PRISMA guidelines. The following electronic databases were accessed in October 2022: PubMed, Scopus, Web of Science. All the clinical studies which investigated the outcomes of MPFL reconstruction using autografts in children and adolescents with recurrent patellofemoral instability were accessed. Only studies which included patients younger than 18 years were considered. Techniques, case reports, guidelines, comments, editorials, letters, protocols, reviews, and meta-analyses were excluded. Studies which included patients with congenital or acute patellofemoral instability were not eligible, nor were those which focused exclusively on hyperlaxity. RESULTS Data from 477 patients (510 procedures) were retrieved. Of the patients, 41% (196 of 477) were women. The mean length of follow-up was 33.7 ± 28.8 months. The mean age of the patients was 14.6 ± 1.6 years. At the last follow-up, all PROMs of interest were statistically improved. The mean time to return to sport was 6.1 ± 1.1 months. Of the patients, 27% reduced their level of activity after surgical stabilization. A total of 87% of patients returned to practice sport. A total of 5% (26 of 477) and 2% (9 of 363) of patients experienced further dislocations and subluxations, respectively, during the follow-up period. Moreover, 4% (16 of 403) of patients underwent a further surgical procedure for patellofemoral instability within the follow-up period. CONCLUSION MPFL reconstruction using autografts is effective in children and adolescents with recurrent patellofemoral instability.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke on Trent ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London E1 4DG, UK
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
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Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella-side fixation technique. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07256-0. [PMID: 36454291 DOI: 10.1007/s00167-022-07256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTape®, FT) is possibly becoming an option to tendon grafts for MPFL-R. Patella-side fixation of FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate patellar tracking considering soft-tissue-based and anchor-based patella-side fixation techniques. METHODS In eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR). RESULTS All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p < 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG). CONCLUSION MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.
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Gonzalez RC, Ryskamp DJ, Swinehart SD, Cavendish PA, Milliron E, DiBartola AC, Duerr RA, Flanigan DC, Magnussen RA. Patellofemoral articular cartilage damage is associated with poorer patient-reported outcomes following isolated medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07221-x. [PMID: 36383223 DOI: 10.1007/s00167-022-07221-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to investigate the impact of articular cartilage damage on outcomes following medial patellofemoral ligament (MPFL) reconstruction. METHODS Record review identified 160 patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. Patient demographics, patellofemoral articular cartilage status at surgery, and patient anatomical measures from imaging were obtained via chart review. Patients were contacted and outcomes assessed through collection of Norwich Patellar Instability (NPI) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity score as well as an assessment for recurrent patellar dislocation. Outcomes of patients with grade 0-II patellofemoral cartilage damage were compared to those of patients with grade III-IV cartilage damage. RESULTS One hundred twenty-two patients (76%) with a minimum of one year follow-up were contacted at a mean of 4.8 years post-operatively. A total of 63 patients (52%) had grade III or IV patellofemoral chondral damage at the time of surgery. The majority of the defects was on the medial patella (46 patients-72%) and the mean patellar defect size was 2.8 cm2. Among 93 patients who completed patient-reported outcome scores, the 52 with grade III or IV chondral damage reported a significantly poorer KOOS Quality of Life than the 44 patients with grade 0 to II chondral damage (p = 0.041), controlling for patient age, sex, BMI, and anatomical factors. CONCLUSION Patients with grade III or IV articular cartilage damage of the patellofemoral joint at the time of MPFL reconstruction demonstrated poorer KOOS knee-related quality of life than patients without grade III or IV articular cartilage damage at a mean of 4.8 years following isolated MPFL reconstruction. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - David J Ryskamp
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Steven D Swinehart
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Eric Milliron
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Robert A Duerr
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA.
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Keeling LE, Curley AJ, Kaarre J, Joly JM, West RV. Medial Patellofemoral Ligament Reconstruction. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221132570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Recurrentlateral patellar dislocation is a devastating condition associated with different pathologies, including medial patellofemoral ligament (MPFL) injury, increased tibial tubercle to trochlear groove (TT-TG) distance, and trochlear dysplasia. This video aims to provide an overview of isolated MPFL reconstruction in a patient with recurrent patellar dislocation and chronic MPFL injury. Indications: Isolated MPFL reconstruction is indicated for patients with recurrent lateral patellar instability following an initial trial of nonoperative management, in the absence of other contributing anatomic factors. Candidates for isolated MPFL reconstruction should have a TT-TG distance of <20 mm, and normal or Dejour type A trochlear morphology. Technique Description: Semitendinosus allograft is used to reconstruct the torn or attenuated MPFL. Following diagnostic arthroscopy, an incision is made over the medial border of the patella and dissection is carried through the skin and subcutaneous tissue to the fascia. Two K-wires are over-drilled and two 3.5-mm Arthrex SwiveLock anchors are placed. The allograft is prepared and whipstitched on both sides. The central portion of the graft is tide down to the anchors. A second incision is then made on the medial side of the knee over the epicondyle. Dissection is carried down to the fascia, and palpation is used to identify Schottles’ point. This is confirmed with fluoroscopy. An 8-mm drill bit is then used to drill to a depth of 60 mm on the femoral side. The grafts are passed one at a time through the femoral tunnel. The femoral side is fixed with an Arthrex BioComposite Interference Screw and the incisions are subsequently irrigated and closed in a layered fashion. Results: MPFL reconstruction demonstrates good functional and clinical outcomes with high rates of patient satisfaction and low rates of failure. A recent systematic review demonstrated an 84% rate of return to sport, improved postoperative outcomes, and pooled risks of recurrent instability and reoperation of less than 5% following isolated MPFL reconstruction. Conclusion: Isolated MPFL reconstruction should be considered for patients with recurrent patellar instability in the absence of other clinical risk factors. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
- Laura E. Keeling
- Orthopaedics and Sports Medicine, Inova, Alexandria, Virginia, USA
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J. Curley
- Orthopaedics and Sports Medicine, Inova, Alexandria, Virginia, USA
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Robin V. West
- Orthopaedics and Sports Medicine, Inova, Alexandria, Virginia, USA
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Knapik DM, McCarthy CF, Drummond I, Liu RW, Gilmore A. Optimal Fluoroscopic Angulation to Determine Intercondylar Notch Violation during Pediatric Medial Patellofemoral Ligament Reconstruction. J Knee Surg 2022; 35:1440-1444. [PMID: 33636742 DOI: 10.1055/s-0041-1724131] [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] [Indexed: 02/07/2023]
Abstract
Previous anatomic data has suggested that during pediatric medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel must be angled distally and anteriorly to avoid damage to the distal femoral physis and then intercondylar notch. The purpose of this study was to determine the optimal degree of fluoroscopic angulation necessary to radiographically determine the presence of intercondylar notch violation. Fourteen adult cadaveric human femora were disarticulated and under fluoroscopic guidance, Schöttle's point was identified. A 0.62-mm Kirschner wire was then drilled through the condyle to create minimal notch violation. The femur was then placed on a level radiolucent table and coronal plane radiographs angled from -15 to 60 degrees were obtained in 5-degree increments to determine the fluoroscopic angle at which intercondylar notch violation was most evident. Grading of optimal fluoroscopic angle between two authors found that violation of the notch was the best appreciated at a mean angle of 43 ± 15 degrees from neutral. Results from this study emphasize the importance of angling the beam to essentially obtain a notch view to assess for a breech.
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Affiliation(s)
- Derrick M Knapik
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Conor F McCarthy
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ian Drummond
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Raymond W Liu
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Allison Gilmore
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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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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Vivekanantha P, Kahlon H, Cohen D, de Sa D. Isolated medial patellofemoral ligament reconstruction results in similar postoperative outcomes as medial patellofemoral ligament reconstruction and tibial-tubercle osteotomy: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 31:2433-2445. [PMID: 36214831 DOI: 10.1007/s00167-022-07186-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine the effect of isolated medial patellofemoral ligament reconstruction (MPFLR) versus concomitant MPFLR and tibial-tubercle osteotomy (TTO) on patient-reported functional outcomes, rate of patellar redislocation, and rate of return to sport in skeletally mature patients with recurrent patellar instability and lateralization as defined by elevated tibial-tubercle trochlear groove (TT-TG) distance. METHODS Three databases MEDLINE, PubMed and EMBASE were searched from inception to July 10th, 2022 for literature outlining the management of patients with TT-TG indices greater than 15 mm with either isolated MPFLR or concomitant MPFLR and TTO procedures. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on functional outcomes via the Kujala anterior knee pain score, redislocation rates, return to sport rates, and complications were recorded. The MINORS score was used for all studies to perform a quality assessment of included studies. RESULTS A total of 31 studies comprising 1405 patients (1452 knees) were included in this review. The mean Kujala score in 13 studies comprising 848 total patients in the isolated MPFLR group was 85.0 (range 80.9-97.5) compared to a score of 83.7 (range 77.2-94.0) in 14 studies comprising 459 patients in the concomitant group. The mean pooled redislocation rate in 19 studies examining isolated MPFLR procedures comprising 948 patients was 3.1% (95% CI 2.1-4.4%, I2 = 7%) as opposed to 3.2% (95% CI 1.9-5.0%, I2 = 0%) in 15 studies comprising 486 patients in the concomitant group. The mean pooled return to sport rate in seven studies with 472 total patients in the isolated MPFLR group was 82% (95% CI 78-86%, I2 = 16%) compared to a score of 92% (95% CI 78-99%, I2 = 58%) in four studies comprising 54 patients in the concomitant group. There were similar complication rates between both treatment groups, including range of motion deficits, fractures, infections, and graft failures. CONCLUSION Isolated MPFLR leads to similar anterior knee pain, similar redislocation rates and lower return to sport rates than concomitant MPFLR and TTO procedures in patients with TT-TG distances greater than 15 mm. Information from this review can aid surgeons in their decision to choose MPFLR versus concomitant procedures for this patient population, and can also guide future studies on this topic. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Harjind Kahlon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada.
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Magnussen RA, Peters NJ, Long J, Pappa N, Schmitt LC, Brunst CL, Kaeding CC, Flanigan DC. Accelerated rehabilitation program following medial patellofemoral ligament reconstruction does not increase risk of recurrent instability. Knee 2022; 38:178-183. [PMID: 36063612 DOI: 10.1016/j.knee.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/13/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, United States.
| | - Nicholas J Peters
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Joseph Long
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Nicholas Pappa
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Laura C Schmitt
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Caroline L Brunst
- Sports Medicine Research Institute, The Ohio State University, United States
| | | | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, United States
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