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Puddu L, Lugani G, Perusi F, Brunialti D, Cont F, Ciatti C, Poleggi E, Locatelli L, Pisanu F, Doria C, Cortese F, Caggiari G. Acute Treatment of Osteochondral Detachment Following Patellar Dislocation: Clinical and Short-Term MRI Follow-Up. Life (Basel) 2024; 14:85. [PMID: 38255700 PMCID: PMC10820480 DOI: 10.3390/life14010085] [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: 11/14/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The aim of our study is to emphasizes the significance of prompt diagnosis and intervention in younger patients affected by osteochondral detachment after patellar dislocation, where the first objective is to minimize in the shortest possible time complications and ingravescence. The method involves a clinical patient assessment and MRI follow-up in subjects who underwent to an immediate surgical intervention for osteochondral damage. METHODS From January 2020 to December 2022, 22 patellar dislocation cases were assessed; osteochondral lesions were identified in 12 (54%) patients; nine of these patients were treated immediately with knee arthroscopy, while in seven instances the osteochondral fragment was reattached using bioabsorbable pins. Post-operative clinical evaluations were conducted at one-, three-, and six-month intervals; finally, a six-month post-operative MRI was performed for all surgically treated patients. RESULTS The MRI evaluations, conducted six months post-operation for all seven patients, indicated successful integration of the reattached osteochondral fragment. Every patient returned to their pre-injury activities after surgery. However, two of them reported mild pain in the anterior region of the knee post-surgery. CONCLUSIONS in young patients, swift diagnosis and immediate surgical intervention for osteochondral detachment resulting from patellar dislocation are crucial. This approach has been identified as the best practice, since it substantially minimizes immediate functional restrictions and significantly lowers the long-term risk of femoral-patellar osteoarthritis.
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Affiliation(s)
- Leonardo Puddu
- Orthopaedic and Traumatology Department, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy; (L.P.); (G.L.); (F.P.); (F.C.); (F.C.)
| | - Giovanni Lugani
- Orthopaedic and Traumatology Department, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy; (L.P.); (G.L.); (F.P.); (F.C.); (F.C.)
| | - Francesco Perusi
- Orthopaedic and Traumatology Department, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy; (L.P.); (G.L.); (F.P.); (F.C.); (F.C.)
| | - Damiano Brunialti
- Orthopaedic and Traumatology Department, University of Verona, 37126 Verona, Italy;
| | - Fabrizio Cont
- Orthopaedic and Traumatology Department, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy; (L.P.); (G.L.); (F.P.); (F.C.); (F.C.)
| | - Corrado Ciatti
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
| | - Eleonora Poleggi
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
| | - Leonardo Locatelli
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
| | - Francesco Pisanu
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
| | - Carlo Doria
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
| | - Fabrizio Cortese
- Orthopaedic and Traumatology Department, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy; (L.P.); (G.L.); (F.P.); (F.C.); (F.C.)
| | - Gianfilippo Caggiari
- Department of Orthopaedics, University of Sassari, 07100 Sassari, Italy; (E.P.); (L.L.); (F.P.); (C.D.); (G.C.)
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Mehl J, Vieider RP, Siebenlist S. Osteoarticular Open Flake Fracture Refixation: The "Parachute" Technique. Arthrosc Tech 2024; 13:102805. [PMID: 38312865 PMCID: PMC10837770 DOI: 10.1016/j.eats.2023.08.010] [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: 06/11/2023] [Accepted: 08/20/2023] [Indexed: 02/06/2024] Open
Abstract
Osteochondral fractures of the patella, also known as "flake fractures," frequently occur after patellar dislocation. In such fractures, a piece of patellar cartilage with subchondral bone breaks off due to patellar dislocation or subsequent reposition. Various surgical techniques have evolved for surgical therapy with the goal of realigning the patellar cartilage. This article presents a cost-effective surgical technique for achieving stable refixation of large osteochondral fragments in patellar flake fractures. The proposed technique entails creating transosseous tunnels in a confluent fashion at the margins, exactly between the fragment and the natural cartilage. Sutures are passed through the established tunnels for flake refixation. This refixation method ensures evenly distributed pressure without penetration of the fragment itself, resulting in the formation of a characteristic parachute configuration composed of confluent bone tunnels and absorbable sutures. The suitability of flake refixation is assessed through an algorithm, allowing for appropriate patient selection. The described technique offers several advantages, including its simplicity and cost-effectiveness, a flexible configuration of the sutures, and the ability to provide stable refixation for large osteochondral fragments.
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Affiliation(s)
- Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Romed P. Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
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Scanlon JP, Raymond AC, Aujla RS, Gohil S, Ebert JR, Lam LO, Malik SS, Simpson A, Otto JH, Neeson D, D'Alessandro P. Combined quadriceps medial patellofemoral ligament reconstruction and osteochondral fixation offers good patient-reported outcomes and low rates of recurrent instability for osteochondral defects secondary to acute patella dislocation. Knee Surg Sports Traumatol Arthrosc 2023; 31:4007-4015. [PMID: 37171605 DOI: 10.1007/s00167-023-07430-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE Chondral injuries secondary to traumatic patella dislocation are common, and a subgroup of these are significant defects with fragments amenable to fixation. There is a paucity of published evidence assessing patients managed with combined acute patellofemoral stabilisation and osteochondral fixation. The purpose of this study is to report the outcomes of patients with osteochondral injuries secondary to acute traumatic patella dislocation treated with combined early fragment fixation and MPFL reconstruction using a quadriceps tendon turndown technique which has distinct advantages for this cohort, including preventing chondral overloading and non-violation of the patella bone. METHODS Patients who underwent combined quadriceps tendon MPFL reconstruction and osteochondral fixation were included. Patient demographics, defect characteristics, complications and reoperations were evaluated. Patients were assessed with Lysholm, Kujala, KOOS-PF scores and satisfaction scale at follow up. Pre-operative MRI was assessed for presence of radiological risk factors for patella dislocation and post-operative MRI was used to assess cartilage quality with MOCART 2.0 score. RESULTS A total of 19 patients (63.2% female) were included. The mean age was 17.4 ± 4.8 years and patients were followed up at a mean 15.8 ± 5.1 months post-surgery. The mean defect size was 2.4 cm2 ± 1.3 cm2, with the most common defect location being the patella (13/19; 68.4%) followed by the lateral femoral condyle (5/19; 26.3%). At final follow up, the overall mean Lysholm, Kujala, and KOOS-PF scores were 84.9 ± 11.1, 89.7 ± 5.8 and 80.6 ± 13.6, respectively. Seventeen patients (89.5%) were satisfied with their outcome. The mean MOCART 2.0 score at final follow-up was 72.5. One patient required medial capsular plication with removal of a loose chondral body and microfracture and 3 knees required minor reoperations. CONCLUSION Combined acute osteochondral fragment fixation and MPFL reconstruction using a quadriceps tendon graft offers good radiological and patient-reported outcomes with high satisfaction and low rates of recurrent patella dislocation. To our knowledge, this is currently the largest series of its kind in the literature and the results of this study provide a rationale for a combined approach using a quadriceps tendon graft for this cohort. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- John P Scanlon
- Orthopaedic Research Foundation of Western Australia, Perth, Australia.
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia.
| | - Antony C Raymond
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Randeep S Aujla
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Satyen Gohil
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Jay R Ebert
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Australia
| | - Li-On Lam
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Shahbaz S Malik
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Ashley Simpson
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
| | - Jacobus H Otto
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Declan Neeson
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
| | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Perth, Australia
- Fiona Stanley Fremantle Hospitals Group, Perth, Australia
- Medical School, Division of Surgery, University of Western Australia, Perth, Australia
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Vesseur MA, van Haasteren JC, Verstraelen FU, Boonen B. Osteochondral impression fracture of the patella after sports collision injury. BMJ Case Rep 2023; 16:e253825. [PMID: 36731939 PMCID: PMC9896215 DOI: 10.1136/bcr-2022-253825] [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] [Indexed: 02/04/2023] Open
Abstract
This article reports a case of a teenager who suffered a frontal collision sports injury. Computed Tomography (CT) revealed a fracture of the inferior pole of the patella without obvious displacement and retro patellar cortical impression with 5 mm step off. Surgical intervention was performed using β-tricalcium phosphate (β-TCP) and 3.0 cannulated screw fixation.At 3-month follow-up, the wound showed good healing. No pain was observed. The patient was able to flex up to 100° with full extension. There were no signs of hydrops with full stability of the knee.Good postoperative results can be obtained in osteochondral impression fractures of the patella using surgical intervention to elevate the osteochondral fragment, graft it with β-TCP and raft it with 3.0 cannulated screws.
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Affiliation(s)
- Maud Am Vesseur
- The Department of Orthopaedic and Trauma Surgery, Zuyderland Medical Centre, Heerlen, Limburg, The Netherlands
| | | | - Freek U Verstraelen
- The Department of Orthopaedic and Trauma Surgery, Zuyderland Medical Centre, Heerlen, Limburg, The Netherlands
| | - Bert Boonen
- The Department of Orthopaedic and Trauma Surgery, Zuyderland Medical Centre, Heerlen, Limburg, The Netherlands
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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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Wu L, Liu C, Jiang B, He L. Treatment of osteochondral fracture of lateral femoral condyle after patella dislocation with anchor absorbable sutures: A new surgical technique and a case report. Medicine (Baltimore) 2022; 101:e32104. [PMID: 36550860 PMCID: PMC9771171 DOI: 10.1097/md.0000000000032104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Osteochondral fracture (OCF) in weight-bearing area of lateral femoral condyle (LFC) is a rare combined injury caused by patellar dislocation. PATIENT CONCERNS A 15-year-old female student accidentally sprained her right knee while participating in sports activities. The patient felt pain in his right knee and limited movement. After hospitalization, the patients underwent computed tomography scan and magnetic resonance examination. DIAGNOSIS According to the imaging results, patellar dislocation combined with OCF of LFC was considered in diagnosis. INTERVENTIONS Through the lateral parapatellar approach, we reduced the osteochondral mass and bundled it with absorbable sutures of anchors. OUTCOMES The functional and radiographic outcome were satisfactory at 18 months after operation. LESSONS Anchor absorbable suture bridge fixation for this kind of OCF is not only effective, but also economical.
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Affiliation(s)
- Liang Wu
- Department of Orthopedic Surgery, First People’s Hospital of Linpin District, Hangzhou, Zhejiang, China
| | - Chao Liu
- Department of General Surgery, Medicine Faculty of Universitas Prima Indonesia, North Sumatra, Indonesia
| | - Bing Jiang
- Department of General Surgery, Daocheng Country People’s Hospital, Sichuan, China
| | - Lijiang He
- Department of Orthopedic Surgery, Second People’s Hospital of Yuhang District, Hangzhou, Zhejiang, China
- * Correspondence: Lijiang He, Department of Orthopedic Surgery, Second People’s Hospital of Yuhang District, Hangzhou, Hangzhou, Zhejiang 311121, China (e-mail: )
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Baker H, Dickherber J, Reddy M, Rizzi A, Kahn A, Athiviraham A. Diagnostic Value of MRI and Radiographs of the Knee to Identify Osteochondral Lesions in Acute Patellar Instability. J Knee Surg 2022; 35:1604-1609. [PMID: 33930898 DOI: 10.1055/s-0041-1729551] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to define the diagnostic value of magnetic resonance imaging (MRI) and plain radiographs (X-ray [XR]) in identifying an osteochondral defect or loose body in patients undergoing operative treatment for patellar instability. A total of 87 patients treated operatively for patellar instability with medial patellofemoral ligament (MPFL) reconstruction between 2015 and 2019 were identified. Inclusion criteria were evidence of clinical patellar instability, preoperative XR and MRI studies, and concomitant diagnostic knee arthroscopy and MPFL reconstruction performed to address patellar instability. Patients were excluded if they had a history of prior procedure for patellar instability on the surgical knee, underwent MPFL reconstruction without concomitant diagnostic knee arthroscopy, or had an anterior cruciate ligament or posterior cruciate ligament deficient knee. Operative notes and arthroscopic images were reviewed to identify osteochondral or chondral injuries and loose bodies noted during diagnostic arthroscopy. The primary outcome was the identification of intra-articular loose bodies, chondral injury, or osteochondral defect on preoperative plain radiographs and MRI in patients with patellar instability. All MRIs were performed on a 3T MRI. The sensitivity and specificity of identifying loose bodies on MRI were 0.52 and 0.92 and on XR were 0.23 and 0.98, respectively. The sensitivity and specificity of identifying osteochondral lesions on MRI were 0.43 and 0.81 and on XR were 0.08 and 0.97, respectively. Of the 87 available reports, 45 (51%) described performing chondroplasty for Outerbridge grade II/III chondral lesions on diagnostic arthroscopy. In conclusion, MRI and XR are poorly sensitive at identifying loose bodies or osteochondral defects after patellar dislocations. The poor sensitivity of imaging studies must be considered when determining whether or not to recommend operative management to a patient with patellar instability. This is a Level IV, diagnostic study.
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Affiliation(s)
- Hayden Baker
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Jason Dickherber
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Manoj Reddy
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Andrew Rizzi
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Adam Kahn
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
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Aitchison AH, Hidalgo Perea S, Schlichte LM, Green DW. Medial patellofemoral ligament reconstruction with simultaneous osteochondral fracture fixation is an effective treatment for adolescent patellar dislocation with osteochondral fractures. J Child Orthop 2022; 16:393-400. [PMID: 36238149 PMCID: PMC9551001 DOI: 10.1177/18632521221119541] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Osteochondral fractures can occur during patellar dislocation and often require treatment. The purpose of this study is to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction. METHODS A retrospective review of a cohort of 365 medial patellofemoral ligament reconstructions by a single surgeon from 2008 to 2019 was performed to identify patients who underwent simultaneous osteochondral fracture fixation with bioabsorbable nails. Demographic data, surgical details, clinical follow-up, and subsequent procedures were collected. RESULTS Forty medial patellofemoral ligament reconstructions with osteochondral fracture fixation were performed by a single surgeon from 2008 to 2019. The average age at surgery was 14.6 years (range 10.7-19.6 years). The average length of follow-up was 2.6 years (range 0.7-7.0 years). Eleven (28%) patients required a second surgery on the ipsilateral knee. One patient had recurrent instability and required revision medial patellofemoral ligament reconstruction and osteochondral allograft. The other 10 patients underwent a second surgery to address cartilage damage or debridement of nails. Of the four patients who required nail debridement, the average number of nails initially placed was 7 ± 1.7. This was significantly more than the patients who did not require second surgery related to nail debridement (4.1 ± 1.6, p < .05). CONCLUSION 28% of patients required a second procedure, most of which involved debridement of unhealed portions of the osteochondral fracture. At 2.6-year follow-up, only 2% of patients had a failure of their osteochondral fracture fixation requiring a cartilage restoration procedure. Osteochondral fracture fixation in adolescents with patellofemoral instability can be effectively treated with fixation and simultaneous medial patellofemoral ligament reconstruction. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
| | | | | | - Daniel W Green
- Daniel W Green, Division of Pediatric
Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New
York, NY 10021, USA.
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Felus J, Kowalczyk B, Starmach M, Wyrobek L. Osteochondral Fractures in Acute Patellar Dislocations in Adolescents: Midterm Results of Surgical Treatment. Orthop J Sports Med 2022; 10:23259671221107608. [PMID: 35859644 PMCID: PMC9289920 DOI: 10.1177/23259671221107608] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/22/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Osteochondral fractures (OCFs) are common injuries during acute patellar
dislocation (APD), carrying a high risk of early joint deterioration if left
untreated. The recommended approach is reduction and stable fixation;
however, data on the results of such treatment are limited. Purpose: To evaluate midterm results of fixation of APD-related OCFs in adolescents
and to identify predictive factors for poor outcomes. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective analysis of adolescent patients who underwent
internal fixation of APD-related OCFs between 2004 and 2015 at a single
tertiary pediatric trauma center. The primary outcome variables included
Knee injury and Osteoarthritis Outcome Score (KOOS), patient satisfaction
(0-10 scale), and sports participation compared with preoperative level.
Secondary outcome variables included relationship between final results and
OCF location (patellofemoral vs tibiofemoral), surgical delay (>6 weeks),
and patellar instability after OCF fixation. OCF healing was evaluated using
magnetic resonance imaging (MRI). Results: Included were 40 patients (19 female, 21 male) with 42 OCFs (29 patellar
OCFs, 13 lateral femoral condyle OCFs). The median patient age at surgery
was 14.5 years (interquartile range [IQR], 13-15.5 years), and median
follow-up was 76 months (IQR, 52.5-95 months). Recurrence of patellar
instability occurred in 27.5% of patients. Median overall KOOS was 93.8
(IQR, 90.8-97.6); KOOS–Symptoms, 92.9 (IQR, 85.7-96.4); KOOS–Pain, 97.2
(IQR, 91.7-100); KOOS–Activities of Daily Living, 100 (IQR, 97.1-100);
KOOS–Sports, 90 (IQR, 80-100); and KOOS–Quality of Life, 78.1 (IQR,
56.2-87.5). Median satisfaction score was 8 (IQR, 8-9), and 16 patients
(40%) returned to sports participation at their preinjury level. MRI scans
revealed a 100% rate of bone healing. Abnormalities exceeding the fracture
area were evident on MRI scans in 86.5% of patients. Recurrence of patellar
instability (even after surgical fixation) and unstable patella at final
follow-up were independent predictors of worse results after OCF
fixation. Conclusion: In the current study, reduction and internal fixation for APD-related OCF in
adolescents yielded favorable midterm outcomes. Recurrence of dislocation
and persistent patellar instability jeopardized clinical results.
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Affiliation(s)
- Jaroslaw Felus
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Bart Kowalczyk
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Michal Starmach
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Lukasz Wyrobek
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
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10
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Ackermann J, Waltenspül M, Merkely G, Germann C, Villefort C, Aufdenblatten C, Fucentese SF. Association of Subchondral Changes With Age and Clinical Outcome in Patients With Osteochondral Fractures in the Knee: MRI Analysis at 1 to 10 Years Postoperatively. Orthop J Sports Med 2022; 10:23259671221113234. [PMID: 35912386 PMCID: PMC9326836 DOI: 10.1177/23259671221113234] [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: 03/20/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Predictive factors influencing outcomes after surgical fixation of osteochondral fractures (OCFs) in the knee, particularly time between injury and surgery, have not been determined. Purpose: To report imaging and clinical outcomes after OCF fixation and to assess the association between clinical scores and patient characteristics, lesion morphology, and appearance on magnetic resonance imaging (MRI) scans. Study Design: Case series; Level of evidence, 4. Methods: We assessed the clinical and imaging outcomes of 19 patients after screw fixation for OCFs in the knee at a minimum follow-up of 1 year. Patient characteristics, lesion morphology, and time from trauma to surgery were reviewed for each patient. At final follow-up, patients completed a 100-point visual analog scale (VAS) for pain, Tegner activity scale, Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction survey. Postoperative MRI scans were assessed using the MOCART (magnetic resonance observation of cartilage repair tissue), Osteochondral Allograft MRI Scoring System, and bone marrow edema (BME) size. Results: The mean patient age at surgery was 21.3 ± 11.4 years, and the median time from trauma to surgery was 10 days (range, 0-143 days). The refixed OCF fragment failed in 1 (5.3%) patient on the lateral condyle at 15 months postoperatively. The mean follow-up for the remaining 18 patients was 4.7 ± 3.2 years, and postoperative outcomes were as follows: VAS pain score, 9.5 ± 17.9; Tegner score, 4.8 ± 2.3; KOOS–Pain, 85.9 ± 17.6, KOOS-Symptoms, 76.4 ± 16.1; KOOS–Activities of Daily Living, 90.3 ± 19.0; KOOS–Sport, 74.4 ± 25.4; and KOOS–Quality of Life, 55.9 ± 24.7. Overall, 84.2% were satisfied or very satisfied with outcomes. Patient age was significantly associated with KOOS subscale scores and subchondral imaging parameters including BME and presence of subchondral cysts, which in turn were the only imaging variables linked to clinical outcomes (P < .05). Time from injury to surgery was not correlated with clinical or imaging outcomes. Conclusion: Fixation of OCFs yielded acceptable clinical and imaging outcomes at a mean 5-year follow-up with seemingly little influence of delayed surgical treatment. Postoperative subchondral changes were significantly associated with clinical outcomes and were linked to patient age at surgery.
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Affiliation(s)
- Jakob Ackermann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Gergo Merkely
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Germann
- Department of Radiology, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Christina Villefort
- Department of Pediatric Surgery, Division of Trauma and Orthopedic Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Christoph Aufdenblatten
- Department of Pediatric Surgery, Division of Trauma and Orthopedic Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Medina Pérez G, Barrow B, Krueger V, Cruz AI. Treatment of Osteochondral Fractures After Acute Patellofemoral Instability: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202204000-00004. [PMID: 35394969 DOI: 10.2106/jbjs.rvw.21.00242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» An osteochondral fracture (OCF) of the patella or the femur is a frequent sequela after an episode of acute patellofemoral instability. » Patients commonly present with anterior knee pain after direct trauma to the patella or a noncontact twisting injury. » Radiographs and magnetic resonance imaging (MRI) are the most common imaging modalities that are used to diagnose OCFs. » Arthroscopy may be indicated in cases of displaced OCFs, and the decision regarding osteochondral fragment fixation or loose body removal depends on fragment size, location, and extent of injury. » Most of the current literature suggests worse outcomes for patients with OCFs who undergo nonoperative treatment, no significant differences in outcomes for patients sustaining an acute patellar dislocation with or without an OCF, and inconclusive results concerning outcomes for patients treated with loose body removal compared with fixation. » Current outcome data are limited by studies with low levels of evidence; therefore, well-designed randomized controlled trials are needed.
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Affiliation(s)
- Giancarlo Medina Pérez
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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12
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Excellent clinical and radiological outcomes after both open flake refixation and autologous chondrocyte implantation following acute patella dislocation and concomitant flake fractures. Knee Surg Sports Traumatol Arthrosc 2022; 30:3334-3342. [PMID: 35218374 PMCID: PMC9464151 DOI: 10.1007/s00167-022-06899-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/20/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate clinical and magnetic resonance (MR) imaging results of patients undergoing patella stabilization with either open flake refixation (oFR) or autologous chondrocyte implantation (ACI) and concomitant soft tissue patella stabilization after sustaining primary, acute patella dislocation with confirmed chondral and/or osteochondral flake fractures. It was hypothesized that refixation will lead to better results than ACI at mid-term follow-up. METHODS A retrospective chart review was conducted to identify all patients undergoing oFR or ACI after sustaining (osteo-)chondral flake fractures and concomitant soft tissue patella stabilization following primary, acute patella dislocation between 01/2012 and 09/2018 at the author's institution. Patients were excluded if they were aged < 14 years or > 30 and had previous knee surgeries at the index knee. Clinical outcomes were assessed using the Tegner activity score, Kujala score, subjective IKDC score, and the KOOS score at a minimum follow-up of 24 months postoperatively. MR images were assessed using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 knee score. Thirty patients were included in the study, with 16 patients assorted to the oFR group and 14 patients to the ACI group (Follow-up 81%). RESULTS Demographic data did not show significant group differences (oFR: 6 females, 10 males; age 26.9 ± 5.6 years, FU: 57 months (27-97 months); ACI: 9 females, 5 males; age 25.5 ± 4.9 years, FU: 51 months (29-91 months); n.s.). Defect location was similar in both groups (oFR: 12 × patella/4 × lateral femoral condyle; ACI: 12/2; n.s.). Both groups showed excellent clinical outcomes, with no statistically significant difference between both the groups (oFR group vs. ACI group: Tegner: 5.1 ± 1.8 vs. 5.1 ± 1.4; Kujala: 86.1 ± 12.6 vs. 84.9 ± 9.1; IKDC: 83.8 ± 15.0 vs. 83.6 ± 11.3; KOOS: 83.3 ± 14.0 vs. 83.6 ± 12.0; n.s.). One patient in each group suffered a patella re-dislocation and needed revision surgery. The MOCART 2.0 score showed good results for the oFR group (68.2 ± 11.1) and the ACI group (61.1 ± 16.9) while no significant differences were noted between both the groups. The inter-rater reliability was excellent (0.847). CONCLUSION Open refixation of (osteo-)chondral fragments in patients after sustaining acute patella dislocation with (osteo)-chondral flake fractures led to good clinical and radiological results at a minimum follow of 24 months, showing that it is a good surgical option in the treatment algorithm. However, if open refixation is not possible, ACI may be an excellent fallback option in these younger patients with equally good clinical and radiological outcomes, but requiring a second minimally invasive surgery. LEVEL OF EVIDENCE III.
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13
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Balcarek P. [Primary and recurrent patellar dislocation: recommendation for diagnostic evaluation, risk stratification and treatment]. SPORTVERLETZUNG-SPORTSCHADEN 2021; 35:185-193. [PMID: 34883518 DOI: 10.1055/a-1667-2241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The dogma that (every) primary patellar dislocation should be treated non-operatively is considered outdated. Therefore, every first-time dislocation, as well as every recurrent dislocation, should be fully diagnosed with regard to the injury pattern and anatomically predisposing risk factors. This enables the use of risk stratification models to assess the risk of recurrent episodes of instability, thereby supporting the clinical decision-making process. The reconstruction of the MPFL can be considered an established and successful treatment strategy for patellar instability. However, the additional correction of bony risk factors is often useful. In this context, the preoperative grading of the J sign and dynamic assessment of patellar instability (dynamic apprehension test) are of utmost importance. These findings, combined with the radiographic imaging findings, can be used as a clinical decision aid for a bony correction procedure.
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Migliorini F, Marsilio E, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. Chondral and Soft Tissue Injuries Associated to Acute Patellar Dislocation: A Systematic Review. Life (Basel) 2021; 11:life11121360. [PMID: 34947891 PMCID: PMC8706453 DOI: 10.3390/life11121360] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Chondral and soft tissue injuries can be associated with first time patellar dislocation, but it is unclear how common they are, and which tissues are affected. A systematic review of the literature was performed to investigate the frequency, location, and extent of chondral and medial patellofemoral ligament (MPFL) injuries in patients following first time patellar dislocation. METHODS This systematic review was conducted according to the PRISMA guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in November 2021. All the published clinical studies reporting the frequency, location, and extent of soft tissue lesions following first time patellar dislocation were accessed. Studies reporting data on habitual, congenital, or recurrent patellofemoral instability were excluded. RESULTS Data from 42 articles (2254 patients, mean age 21.6 ± 7.3 years) were retrieved. Ninety-eight percent of patients who experienced first time patellar dislocation demonstrated MPFL rupture at MRI. Forty-eight percent of MPFL ruptures were located at the patellar side, 34% at the femoral insertion site, and 18% in the midportion. Eighty-five percent of patients showed signs of patellar chondral damage at MRI, and trochlear chondral injuries were evidenced in 47% of patients. Intra-articular loose bodies were observed in 11.5% of patients. At arthroscopy, the medial facet and the crest of the patella more commonly exhibited chondral lesions than the lateral facet and femoral trochlea. CONCLUSIONS Most patients suffer chondral damage and MPFL tears following after a first time patellar dislocation.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Emanuela Marsilio
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Cuozzo
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Oliva
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Jörg Eschweiler
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Frank Hildebrand
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Nicola Maffulli
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London E1 4DG, UK
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST5 5BG, UK
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Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques. Life (Basel) 2021; 11:life11060543. [PMID: 34200546 PMCID: PMC8226590 DOI: 10.3390/life11060543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
Large (>3 cm2), focal osteochondral lesions (OCL) may result in poor functional outcomes and early secondary osteoarthritis of the knee. The surgical management of these OCL remains challenging. The treatment strategy must be tailored to various aspects, including lesion-specific (e.g., size, location, chronicity), joint-specific (e.g., instability, limb alignment, meniscal status), and patient-specific factors (e.g., age, activity level, comorbidities). Simple chondroplasty and bone marrow stimulation (BMS) techniques should be reserved for smaller lesions, as they only realize midterm clinical benefits, related to inferior wear characteristics of the induced fibrocartilage (type I collagen). Therefore, much attention has been focused on surgical restoration with hyaline cartilage (type II collagen), based on chondrocyte transplantation and matrix-assisted autologous chondrocyte implantation (MACI). Limited graft availability, staged procedures (MACI), and high treatment costs are limitations of these techniques. However, acute traumatic OCL of the femoral condyles and patellofemoral joint may also be suitable for preservation by surgical fixation. Early detection of the fragment facilitates primary repair with internal fixation. The surgical repair of the articular surface may offer promising clinical and cost-effective benefits as a first-line therapy but remains under-investigated and potentially under-utilized. As a unique characteristic, the fixation technique allows the anatomic restoration of the hyaline articular surface with native cartilage and the repair of the subchondral bone. In this manuscript, we present a case series of large OCL around the knee that were preserved by surgical fixation. Furthermore, various implants and techniques reported for this procedure are reviewed.
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Niethammer T. [13/f-The dislocated kneecap : Preparation for the medical specialist examination: part 72]. Unfallchirurg 2021; 124:200-205. [PMID: 33728489 DOI: 10.1007/s00113-021-00980-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Thomas Niethammer
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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17
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Tanikella AS, Hardy MJ, Frahs SM, Cormier AG, Gibbons KD, Fitzpatrick CK, Oxford JT. Emerging Gene-Editing Modalities for Osteoarthritis. Int J Mol Sci 2020; 21:ijms21176046. [PMID: 32842631 PMCID: PMC7504272 DOI: 10.3390/ijms21176046] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Osteoarthritis (OA) is a pathological degenerative condition of the joints that is widely prevalent worldwide, resulting in significant pain, disability, and impaired quality of life. The diverse etiology and pathogenesis of OA can explain the paucity of viable preventive and disease-modifying strategies to counter it. Advances in genome-editing techniques may improve disease-modifying solutions by addressing inherited predisposing risk factors and the activity of inflammatory modulators. Recent progress on technologies such as CRISPR/Cas9 and cell-based genome-editing therapies targeting the genetic and epigenetic alternations in OA offer promising avenues for early diagnosis and the development of personalized therapies. The purpose of this literature review was to concisely summarize the genome-editing options against chronic degenerative joint conditions such as OA with a focus on the more recently emerging modalities, especially CRISPR/Cas9. Future advancements in novel genome-editing therapies may improve the efficacy of such targeted treatments.
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Affiliation(s)
- Alekya S. Tanikella
- Biomolecular Research Center, Boise State University, Boise, ID 83725, USA; (A.S.T.); (M.J.H.); (S.M.F.)
| | - Makenna J. Hardy
- Biomolecular Research Center, Boise State University, Boise, ID 83725, USA; (A.S.T.); (M.J.H.); (S.M.F.)
- Department of Biological Sciences, Boise State University, Boise, ID 83725, USA
- Biomolecular Sciences Graduate Programs, Boise State University, Boise, ID 83725, USA
| | - Stephanie M. Frahs
- Biomolecular Research Center, Boise State University, Boise, ID 83725, USA; (A.S.T.); (M.J.H.); (S.M.F.)
- Department of Biological Sciences, Boise State University, Boise, ID 83725, USA
- Biomolecular Sciences Graduate Programs, Boise State University, Boise, ID 83725, USA
| | - Aidan G. Cormier
- Mechanical and Biomedical Engineering, Boise State University, Boise, ID 83725, USA; (A.G.C.); (K.D.G.); (C.K.F.)
| | - Kalin D. Gibbons
- Mechanical and Biomedical Engineering, Boise State University, Boise, ID 83725, USA; (A.G.C.); (K.D.G.); (C.K.F.)
| | - Clare K. Fitzpatrick
- Mechanical and Biomedical Engineering, Boise State University, Boise, ID 83725, USA; (A.G.C.); (K.D.G.); (C.K.F.)
| | - Julia Thom Oxford
- Biomolecular Research Center, Boise State University, Boise, ID 83725, USA; (A.S.T.); (M.J.H.); (S.M.F.)
- Department of Biological Sciences, Boise State University, Boise, ID 83725, USA
- Biomolecular Sciences Graduate Programs, Boise State University, Boise, ID 83725, USA
- Correspondence: ; Tel.: +1-208-426-2395
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18
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Vogel LA, Fitzsimmons KP, Lee Pace J. Osteochondral Fracture Fixation With Fragment Preserving Suture Technique. Arthrosc Tech 2020; 9:e761-e767. [PMID: 32577349 PMCID: PMC7301336 DOI: 10.1016/j.eats.2020.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/04/2020] [Indexed: 02/03/2023] Open
Abstract
Osteochondral fractures are relatively uncommon injuries that typically present after an acute or subacute traumatic injury. Osteochondral fracture fixation is traditionally performed in the acute setting with internal fixation procedures using pins or compression screws through the fragment. Outcomes have generally been good, but cartilage thinning, subchondral remodeling, and tissue reactions can occur after internal fixation through the fragment. This article describes osteochondral fracture fragment fixation with a fragment-preserving technique that does not violate the articular cartilage of the fragment. This technique minimizes risk to articular cartilage that has already sustained injury and also provides superior fixation.
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Affiliation(s)
- Laura A. Vogel
- Department of Orthopaedics, University of Colorado, Aurora, Colorado
| | - Kevin P. Fitzsimmons
- Elite Sports Medicine, Connecticut Children's Medical Center, Farmington, Connecticut, U.S.A
| | - J. Lee Pace
- Elite Sports Medicine, Connecticut Children's Medical Center, Farmington, Connecticut, U.S.A.,Department of Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A.,Address correspondence to J. Lee Pace, M.D., Elite Sports Medicine, Connecticut Children's Medical Center, 399 Farmington Ave, Farmington, CT 06032, U.S.A.
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