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Alshaban RM, Ghaddaf AA, Alghamdi DM, Aghashami A, Alqrni A, Alyasi AA, Bogari H, Qadi S. Operative versus non-operative management of primary patellar dislocation: A systematic review and network meta-analysis. Injury 2023; 54:110926. [PMID: 37473507 DOI: 10.1016/j.injury.2023.110926] [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: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Acute patellar dislocation is a common knee injury in adolescents and adults that is associated with a high incidence of medial patellofemoral ligament (MPFL) injuries. The aim of this network meta-analysis was to compare the different operative and non-operative protocols for the management of primary patellar dislocation (PPD). METHODS We searched Medline, Embase, and CENTRAL databases. We included randomized controlled trials (RCTs) that compared operative and non-operative protocols for adolescent or adult patients with acute traumatic PPD. We sought to evaluate the clinical and functional outcomes of each management protocol by considering the results of Kujala score, Tegner activity score, redislocation rate, and subluxation rate. The effectiveness of the different management protocols was measured through frequentist network meta-analysis, using the Netmeta statistical package in R software. All treatment protocols were ranked using the netrank function, yielding P scores. RESULTS A total of 10 RCTs were deemed eligible. As per P-scores, open MPFL repair yielded the highest effectiveness with respect to Kujala score (P=0.81) and lowest odds for redislocation (P=0.14) whereas arthroscopic MPFL repair yielded the highest effectiveness with respect to Tegner activity score (P=0.85) and lowest odds for subluxation (P=0.21). Arthroscopic MPFL repair showed a significant reduction in redislocation and subluxation rate. CONCLUSION This network meta-analysis demonstrated arthroscopic MPFL repair is the most effective treatment protocol for the management of acute primary patellar dislocation.
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Affiliation(s)
- Raneem M Alshaban
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Dalia M Alghamdi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Afnan Aghashami
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ali Alqrni
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulrahman A Alyasi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan Bogari
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Sara Qadi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Orthopedic Surgery Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Samelis PV, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus 2023; 15:e46743. [PMID: 38021800 PMCID: PMC10631568 DOI: 10.7759/cureus.46743] [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] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
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Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis and Aglaia Kyriakou, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Panagiotis Koulouvaris
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Olga Savvidou
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Andreas Mavrogenis
- Orthopaedics, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Panayiotis J Papagelopoulos
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
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Ryan PC, Ross BJ, Stamm MA, Sherman WF, Heard WMR, Mulcahey MK. Concomitant Tibial Tubercle Osteotomy Reduces the Risk of Revision Surgery After Medial Patellofemoral Ligament Reconstruction for the Treatment of Patellar Instability. Arthroscopy 2023; 39:2037-2045.e1. [PMID: 36804459 DOI: 10.1016/j.arthro.2023.02.006] [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: 06/24/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To compare postoperative complication rates between patients who underwent medial patellofemoral ligament reconstruction (MPFLR) and those who underwent MPFLR with tibial tubercle osteotomy (TTO) in a large-scale study. A secondary goal was to investigate demographic associations with outcomes. METHODS Patients who underwent MPFLR (n = 3,480) or MPFLR-TTO (n = 615) for patellar instability were identified in the PearlDiver database. Rates of surgery for infection, procedures for knee stiffness, patellar fracture, and revision MPFLR within 2 years postoperatively were compared using multivariable logistic regression. Demographic associations with outcomes were also investigated. RESULTS The MPFLR-TTO cohort exhibited a significantly lower rate of revision surgery at 2 years (0.8% vs 1.9%; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.10-0.80; P = .036) when compared with the MPFLR group. Independent of index procedure, patients younger than 21 years had significantly lower rates of requiring procedures for knee stiffness (OR, 0.35; 95% CI, 0.22-0.54; P < .001) and any complication at 2 years (OR, 0.59; 95% CI, 0.45-0.78; P < .001) when compared with older patients. Male patients displayed a significantly lower rate of requiring procedures for knee stiffness at 2 years than female patients (OR, 0.46; 95% CI, 0.25-0.78; P = .007). Tobacco use was associated with a significantly higher rate of postoperative infection at 2 years (OR, 2.35; 95% CI, 1.00-5.38; P = .046). CONCLUSIONS The MPFLR cohort exhibited higher rates of revision surgery at 2 years compared with the MPFLR-TTO cohort. Patient age under 21 years was associated with lower rates of any complication and requiring procedures for knee stiffness, male sex was associated with a lower rate of requiring procedures for knee stiffness, and tobacco use was associated with a higher rate of surgery for postoperative infection. This information can assist surgeons when counseling patients before these procedures are performed. LEVEL OF EVIDENCE Level III, retrospective, comparative prognostic trial.
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Affiliation(s)
- Patrick C Ryan
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Bailey J Ross
- Department of Orthopaedic Surgery, Emory School of Medicine, Atlanta, Georgia, U.S.A
| | - Michaela A Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Wendell M R Heard
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
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Lee DY, Kang DG, Jo HS, Heo SJ, Bae JH, Hwang SC. A systematic review and meta-analysis comparing conservative and surgical treatments for acute patellar dislocation in children and adolescents. Knee Surg Relat Res 2023; 35:18. [PMID: 37349852 DOI: 10.1186/s43019-023-00189-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/02/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE This study sought to clarify treatment evidence to treat patellar dislocation by evaluating which treatment could yield better improvement of clinical outcomes for acute patellar dislocation in children and adolescents 18 years of age or younger. MATERIALS AND METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials electronic databases were searched for relevant articles comparing clinical outcomes of conservative and surgical treatments for acute patellar dislocation in children and adolescents published from March 2008 to August 2022. Data searching, extraction, analysis, and quality assessment were performed on the basis of the Cochrane Collaboration guidelines. The quality assessment of each study was investigated using the Physiotherapy Evidence Database (PEDro) critical appraisal scoring system and Newcastle-Ottawa Quality Assessment Scale scores. To calculate the overall combined effect size for each outcome, Review Manager Version 5.3 (The Cochrane Collaboration, Software Update, Oxford) was employed. RESULTS Three randomized controlled trials (RCTs) and one prospective study were investigated. In terms of pain [mean difference (MD) 6.59, 95% confidence interval (CI) 1.73-11.45, I2 0%], there were significantly better outcomes in conservative group. Nevertheless, there were no significant differences in any evaluated outcomes such as redislocation [risk ratio (RR) 1.36, 95% CI 0.72-2.54, I2 65%], Kujala score (MD 3.92, 95% CI -0.17 to 8.01, I2 0%), Tegner score (MD 1.04, 95% CI -0.04 to 2.11, I2 71%), or subjective results (RR 0.99, 95% CI 0.74-1.34, I2 33%) between conservative and surgical treatment groups. CONCLUSIONS Despite better pain outcomes with conservative group, the present study revealed no significant differences in clinical outcomes between conservative treatment and surgical treatment in children and adolescents with acute patellar dislocation. Since there are no significant differences in clinical outcomes between the two groups, routine surgical treatment is not advocated for treating acute patellar dislocation in children and adolescents.
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Affiliation(s)
- Dong-Yeong Lee
- Department of Orthopaedic Surgery, Barun Hospital, Jinju, Republic of Korea
| | - Dong-Geun Kang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Changwon Hospital, Changwon, Republic of Korea
| | - Ho-Seung Jo
- Department of Orthopaedic Surgery, SMG Yeonse Hospital, Changwon, Republic of Korea
| | - Se-Joon Heo
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Ji-Ho Bae
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Sun-Chul Hwang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea.
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Sinikumpu J, Nicolaou N. Current concepts in the treatment of first-time patella dislocation in children and adolescents. J Child Orthop 2023; 17:28-33. [PMID: 36755554 PMCID: PMC9900011 DOI: 10.1177/18632521221149060] [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: 11/20/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023] Open
Abstract
Background Lateral dislocation of the patella is a common injury in children. It can occur in previously healthy and anatomically normal knees, but there are several abnormalities that predispose to patellar instability. Magnetic resonance imaging is an essential part of assessing for associated injuries and risk of further instability. Treatment aims to prevent redislocation, residual instability, osteoarthritis, and allow return to previous activities. The purpose of this review was to assess evidence for management of first-time patella dislocation in children and adolescents. Methods Literature review was performed, accompanied by the current best practice by the authors. Results Non-operative treatment is preferred, except where there are associated injuries such as osteochondral fractures that would benefit from surgery. The exact method of ideal non-operative management is not clearly defined but should focus on restoration of range of movement and strength with bracing as indicated. There seems to be a trend toward operative intervention that may well be inappropriate. Conclusion Further prospective studies are required with focus on the younger patient to fully understand if there is an at-risk group that would benefit from early surgery. Level of evidence level III.
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Affiliation(s)
- Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopaedics, Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Nicolas Nicolaou
- Department of Paediatric Orthopaedic Surgery, Sheffield Children’s Hospital, Sheffield, UK
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Smith TO, Gaukroger A, Metcalfe A, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2023; 1:CD008106. [PMID: 36692346 PMCID: PMC9872769 DOI: 10.1002/14651858.cd008106.pub4] [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: 01/25/2023]
Abstract
BACKGROUND Patellar (knee cap) dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. It affects up to 42/100,000 people, and is most prevalent in those aged 20 to 30 years old. It is uncertain whether surgical or non-surgical treatment is the best approach. This is important as recurrent dislocation occurs in up to 40% of people who experience a first time (primary) dislocation. This can reduce quality of life and as a result people have to modify their lifestyle. This review is needed to determine whether surgical or non-surgical treatment should be offered to people after patellar dislocation. OBJECTIVES To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL, Physiotherapy Evidence Database and trial registries in December 2021. We contacted corresponding authors to identify additional studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating primary or recurrent lateral patellar dislocation in adults or children. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were recurrent patellar dislocation, and patient-rated knee and physical function scores. Our secondary outcomes were health-related quality of life, return to former activities, knee pain during activity or at rest, adverse events, patient-reported satisfaction, patient-reported knee instability symptoms and subsequent requirement for knee surgery. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 10 studies (eight randomised controlled trials (RCTs) and two quasi-RCTs) of 519 participants with patellar dislocation. The mean ages in the individual studies ranged from 13.0 to 27.2 years. Four studies included children, mainly adolescents, as well as adults; two only recruited children. Study follow-up ranged from one to 14 years. We are unsure of the evidence for all outcomes in this review because we judged the certainty of the evidence to be very low. We downgraded each outcome by three levels. Reasons included imprecision (when fewer than 100 events were reported or the confidence interval (CI) indicated appreciable benefits as well as harms), risk of bias (when studies were at high risk of performance, detection and attrition bias), and inconsistency (in the event that pooled analysis included high levels of statistical heterogeneity). We are uncertain whether surgery lowers the risk of recurrent dislocation following primary patellar dislocation compared with non-surgical management at two to nine year follow-up. Based on an illustrative risk of recurrent dislocation in 348 people per 1000 in the non-surgical group, we found that 157 fewer people per 1000 (95% CI 209 fewer to 87 fewer) had recurrent dislocation between two and nine years after surgery (8 studies, 438 participants). We are uncertain whether surgery improves patient-rated knee and function scores. Studies measured this outcome using different scales (the Tegner activity scale, Knee Injury and Osteoarthritis Outcome Score, Lysholm, Kujala Patellofemoral Disorders score and Hughston visual analogue scale). The most frequently reported score was the Kujala Patellofemoral Disorders score. This indicated people in the surgical group had a mean score of 5.73 points higher at two to nine year follow-up (95% CI 2.91 lower to 14.37 higher; 7 studies, 401 participants). On this 100-point scale, higher scores indicate better function, and a change score of 10 points is considered to be clinically meaningful; therefore, this CI includes a possible meaningful improvement. We are uncertain whether surgery increases the risk of adverse events. Based on an assumed risk of overall incidence of complications during the first two years in 277 people out of 1000 in the non-surgical group, 335 more people per 1000 (95% CI 75 fewer to 723 more) had an adverse event in the surgery group (2 studies, 144 participants). Three studies (176 participants) assessed participant satisfaction at two to nine year follow-up, reporting little difference between groups. Based on an assumed risk of 763 per 1000 non-surgical participants reporting excellent or good outcomes, seven more participants per 1000 (95% CI 199 fewer to 237 more) reported excellent or good satisfaction. Four studies (256 participants) assessed recurrent patellar subluxation at two to nine year follow-up. Based on an assumed risk of patellar subluxation in 292 out of 1000 in the non-surgical group, 73 fewer people per 1000 (95% CI 146 fewer to 35 more) had patellar subluxation as a result of surgery. Slightly more people had subsequent surgery in the non-surgical group. Pooled two to nine year follow-up data from three trials (195 participants) indicated that, based on an assumed risk of subsequent surgery in 215 people per 1000 in the non-surgical group, 118 fewer people per 1000 (95% CI 200 fewer to 372 more) had subsequent surgery after primary surgery. AUTHORS' CONCLUSIONS We are uncertain whether surgery improves outcome compared to non-surgical management as the certainty of the evidence was very low. No sufficiently powered trial has examined people with recurrent patellar dislocation. Adequately powered, multicentre, randomised trials are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the pathological variations that may be relevant to both choice of these interventions.
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Affiliation(s)
- Toby O Smith
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andrew Gaukroger
- Trauma and Orthopaedics, St George's University Hospital NHS trust, London, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Caroline B Hing
- Department of Trauma and Orthopaedic Surgery, St George's Hospital, London, UK
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Parikh SN, Veerkamp M, Redler LH, Schlechter J, Williams BA, Yaniv M, Friel N, Perea SH, Shannon SR, Green DW. Patellar Instability in Young Athletes. Clin Sports Med 2022; 41:627-651. [DOI: 10.1016/j.csm.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Orellana KJ, Batley MG, Lawrence JTR, Nguyen JC, Williams BA. Radiographic Evaluation of Pediatric Patients with Patellofemoral Instability. Curr Rev Musculoskelet Med 2022; 15:411-426. [PMID: 35932425 DOI: 10.1007/s12178-022-09780-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the radiographic assessments of utility in the evaluation of a pediatric patient with patellofemoral instability to facilitate a thorough work-up. Understanding of these measures is useful in understanding evolving research in this field, providing accurate patient risk assessment, and appropriately directing surgical decision-making. RECENT FINDINGS Recent literature has broadened the radiographic characterization of the pediatric patellar instability and its anatomic risk factors. Knee MRI can inform the assessment of skeletal maturity and novel axial alignment measurements may enhance our identification of patients at increased risk of recurrent instability. Additional improvements have been made in the objective measurement and classification of trochlear dysplasia. Knee MRI-based skeletal age assessments may obviate the need for hand bone age assessments in growing children with patellofemoral instability. Novel objective measures exist in the evaluation of pediatric patellar instability both in the assessment of axial alignment and trochlear dysplasia. Future work should focus on how these measures can aid in guiding surgical decision-making.
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Affiliation(s)
- Kevin J Orellana
- University of Texas Rio Grande Valley School of Medicine, Edinburg, TX, USA
| | - Morgan G Batley
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Todd R Lawrence
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jie C Nguyen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brendan A Williams
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Migliorini F, Pilone M, Eschweiler J, Marsilio E, Hildebrand F, Maffulli N. High Rates of Damage to the Medial Patellofemoral Ligament, Lateral Trochlea, and Patellar Crest After Acute Patellar Dislocation: Magnetic Resonance Imaging Analysis. Arthroscopy 2022; 38:2472-2479. [PMID: 35157964 DOI: 10.1016/j.arthro.2022.01.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary outcome of interest of this study was to determine the frequency, location, and extent of chondral injuries and medial patellofemoral ligament (MPFL) tears, along with the rate of loose bodies, in the knee after acute primary patellar dislocation. The secondary outcome of interest was to conduct a multivariate analysis to investigate whether the presence of pathoanatomic abnormalities, including structural differences in the knees of the patients, is associated with the features of the lesions. METHODS Patients who underwent magnetic resonance imaging after primary acute patellar dislocation were identified from our institutional databases. We analyzed a total of 175 magnetic resonance imaging scans of patients aged between 14 and 25 years who were eligible for inclusion. RESULTS Chondral damage to the medial facet of the patella was present in 36 patients; patellar crest, 78 patients; and lateral patellar facet, 28 patients. One patient presented with chondral defects in the medial trochlear facet, whereas 118 patients showed chondral defects in the lateral trochlear facet. Loose bodies were present in 142 patients. A total of 161 patients (92%) showed MPFL damage. The patellar portion was affected in 119 patients. Of the patients, 28 showed a partially damaged MPFL (<50%), 42 showed MPFL damage greater than 50%, and 49 presented with a complete tear of the MPFL. MPFL lesions were observed on the femoral side in 42 patients. Fourteen patients presented with an avulsion fracture on the patellar side; 28 patients, on the femoral side. CONCLUSIONS The MPFL was injured in 92% of 175 patients after a first-time acute patellar dislocation. Chondral damage was most frequent at the patellar crest, followed by the lateral femoral epicondyle. No association was found between patella alta, the sulcus angle, the Q angle, the tibial tubercle-trochlear groove distance, trochlear and patellar dysplasia, and soft-tissue damage. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marco Pilone
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Jörg Eschweiler
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Emanuela Marsilio
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy; Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, England; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, England
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10
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Giesler P, Baumann FA, Weidlich D, Karampinos DC, Jung M, Holwein C, Schneider J, Gersing AS, Imhoff AB, Bamberg F, Jungmann PM. Patellar instability MRI measurements are associated with knee joint degeneration after reconstruction of the medial patellofemoral ligament. Skeletal Radiol 2022; 51:535-547. [PMID: 34218322 PMCID: PMC8763754 DOI: 10.1007/s00256-021-03832-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To qualitatively and quantitatively evaluate the 2-year magnetic resonance imaging (MRI) outcome after MPFL reconstruction at the knee and to assess MRI-based risk factors that predispose for inferior clinical and imaging outcomes. MATERIALS AND METHODS A total of 31 patients with MPFL reconstruction were included (22 ± 6 years, 10 female). MRI was performed preoperatively in 21/31 patients. Two-year follow-up MRI included quantitative cartilage T2 and T1rho relaxation time measurements at the ipsilateral and contralateral knee. T2relative was calculated as T2patellofemoral/T2femorotibial. Morphological evaluation was conducted via WORMS scores. Patellar instability parameters and clinical scores were obtained. Statistical analyses included descriptive statistics, t-tests, multivariate regression models, and correlation analyses. RESULTS Two years after MPFL reconstruction, all patellae were clinically stable. Mean total WORMS scores improved significantly from baseline to follow-up (mean difference ± SEM, - 4.0 ± 1.3; P = 0.005). As compared to patients with no worsening of WORMS subscores over time (n = 5), patients with worsening of any WORMS subscore (n = 16) had lower trochlear depth, lower facetal ratio, higher tibial-tuberosity to trochlear groove (TTTG) distance, and higher postoperative lateral patellar tilt (P < 0.05). T2relative was higher at the ipsilateral knee (P = 0.010). T2relative was associated with preoperatively higher patellar tilt (P = 0.021) and higher TTTG distance (P = 0.034). TTTG distance, global T2 values, and WORMS progression correlated with clinical outcomes (P < 0.05). CONCLUSION MPFL reconstruction is an optimal treatment strategy to restore patellar stability. Still, progressive knee joint degeneration and patellofemoral cartilage matrix degeneration may be observed, with patellar instability MRI parameters representing particular risk factors.
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Affiliation(s)
- Paula Giesler
- Department of Diagnostic and Interventional Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Frederic A. Baumann
- Clinical and Interventional Angiology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Dominik Weidlich
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Dimitrios C. Karampinos
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Matthias Jung
- Department of Diagnostic and Interventional Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Christian Holwein
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Julia Schneider
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Alexandra S. Gersing
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
- Department of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Andreas B. Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Pia M. Jungmann
- Department of Diagnostic and Interventional Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
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Clinical Outcomes of Revision Biceps Tenodesis for Failed Long Head of Biceps Surgery: A Systematic Review. Arthroscopy 2021; 37:3529-3536. [PMID: 34023436 DOI: 10.1016/j.arthro.2021.04.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/24/2021] [Accepted: 04/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We summarize the indications, assess the modes of failure, and analyze the clinical and functional outcomes of revision biceps tenodesis after failed primary surgical treatment of long head of biceps (LHB) pathology. METHODS A computerized search of PubMed, EMBASE, and CINAHL databases and manual screening of selected article reference lists was performed in September 2020. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision biceps tenodesis following failed LHB surgery were eligible. Patient demographics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Functional assessment and pain scores were assessed and summarized as forest plots with means and 95% confidence intervals. RESULTS Five of 465 identified studies met inclusion criteria, encompassing 70 revision biceps tenodesis procedures with mean follow-up of 2.4-6.4 years. The failed index procedure was biceps tenodesis in 62 patients and tenotomy in 8 patients. The most common indications for revision were pain or cramping and rerupture, cited by 4 and 3 articles, respectively. After failed conservative treatment, open subpectoral revision tenodesis was performed with concomitant arthroscopic debridement in 65 of 70 cases. Common intraoperative findings at time of revision were adhesions or scarring (39.0-83.0%), fixation failure (8.7-75.0%), and biceps rupture (17.4-80.0%). Revision tenodesis patients reported good to excellent functional outcomes with improvements in Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons Shoulder, and visual analog scale pain scores, and satisfaction ranged from 88.0 to 100%. All studies demonstrated moderate quality of evidence and risk of bias when critically appraised. CONCLUSION This systematic review of 5 moderate risk of bias studies demonstrated that the most common reasons for revision biceps tenodesis were pain or cramping and rerupture. Open subpectoral revision tenodesis with concomitant arthroscopic debridement provided improvements in functional scores with high patient satisfaction at mid-term follow up. LEVEL OF EVIDENCE IV, Systematic Review of level III and IV investigations.
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12
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Abstract
Patellar instability is a broad term that encompasses patellar dislocation, patellar subluxation, and patellar instability. Although both functional and anatomic considerations contribute to symptoms of patellar instability, the most important are thought to be patella alta, trochlear dysplasia, and lateralization of the tibial tubercle. In patients with a history suspicious for prior patellar dislocation, careful evaluation of MRI and radiographic studies can reveal characteristic findings. The most common methods to address patellofemoral instability are medial patellofemoral ligament reconstruction and tibial tubercle osteotomy with either anteromedialization or medialization. Less commonly trochleoplasty is indicated as well. Patients may be treated with one of or a combination of these techniques, each of which has specific indications and complications.
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Affiliation(s)
- Erin McCrum
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA.
| | - Kyle Cooper
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke Health Heritage, Duke University School of Medicine, 3000 Rogers Road, Wake Forest, Durham, NC 27587, USA
| | - Robert J French
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
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