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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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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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Hurley ET, Colasanti CA, Anil U, McAllister D, Matache BA, Alaia MJ, Strauss EJ, Campbell KA. Management of Patellar Instability: A Network Meta-analysis of Randomized Control Trials. Am J Sports Med 2022; 50:2561-2567. [PMID: 34339311 DOI: 10.1177/03635465211020000] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues. PURPOSE To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability. STUDY DESIGN Systematic review and network meta-analysis; Level of evidence, 1. METHODS The literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability were included. Clinical outcomes included recurrent instability (including both dislocations and subluxations), redislocation, and Kujala score. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using the statistical software R. The treatment options were ranked using P scores. RESULTS There were 13 RCTs with a total of 789 patients, all with a minimum follow-up of 24 months. There were 150 patients treated using MPFL reconstruction, 353 treated using MPFL repair, and 286 treated nonoperatively. Overall, MPFL reconstruction had the highest P score (0.9967) and resulted in a significantly lower recurrence rate than did MPFL repair (odds ratio [OR], 0.42; 95% CI, 0.07-0.72) and nonoperative management (OR, 0.09; 95% CI, 0.03-0.32). In addition, MPFL repair resulted in a significantly lower recurrence rate than did nonoperative management (OR, 0.42; 95% CI, 0.25-0.70). MPFL reconstruction had the highest P score (0.9651) and resulted in a significantly higher Kujala score than did nonoperative management (mean difference, 10.45; 95% CI, 0.41-20.49) but not MPFL repair (mean difference, 0.15; 95% CI, 0.03-0.68). Subgroup analysis revealed that MPFL reconstruction had the highest P score for all outcomes in those with first-time dislocation. CONCLUSION The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.
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Abstract
Patellar instability is one of the most prevalent knee disorders, with dislocations occurring in 5 to 43 cases per 10,000 annually. Traumatic patellar dislocation can result in significant morbidity and is associated with patellofemoral chondral injuries and fractures, medial soft tissue disruption, pain, and reduced function, and can lead to patellofemoral osteoarthritis. Chronic and recurrent instability can lead to deformation and incompetence of the medial soft tissue stabilizers. Despite recent gains in understanding the pathoanatomy of this disorder, the management of patients with this condition is complex and remains enigmatic.
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Migliorini F, Eschweiler J, Betsch M, Knobe M, Tingart M, Maffulli N. Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review. Surgeon 2021; 20:e112-e121. [PMID: 33962891 DOI: 10.1016/j.surge.2021.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/28/2021] [Accepted: 03/16/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Evidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability. MATERIAL AND METHODS This study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up. RESULTS A total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced. CONCLUSION The time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Matthias Knobe
- Department of Orthopaedics and Trauma Surgery, University Medical Centre Mannheim of the University Heidelberg, 68167 Mannheim, Germany
| | - Markus Tingart
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England, UK.
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Puijk R, Rassir R, Louwerens JKG, Sierevelt IN, de Jong T, Nolte PA. Evaluation of the 'Spaarne soft tissue procedure' as a treatment for recurrent patellar dislocations: a four-in-one technique. J Exp Orthop 2021; 8:31. [PMID: 33877457 PMCID: PMC8058128 DOI: 10.1186/s40634-021-00349-8] [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: 02/14/2021] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The 'Spaarne soft tissue procedure', is a 4-in-1 soft tissue procedure that treats recurrent patellar dislocations in the young and active population. The procedure has not yet described elsewhere. The purpose of this study is to analyse the redislocation rate and to evaluate the postoperative knee function and patient satisfaction. METHODS Twenty-seven patients (34 knees) underwent the four-in-one SST-procedure. The 4-step technique required a minor change in 2010, including the use of a smaller strip of the patellar tendon for transposition. After a median follow-up of 10.4 years, the redislocation rate was evaluated as the primary outcome measure. Secondary outcome measures were functional outcome (IKDC, Kujala, Lysholm and Tegner activity scale) and Numeric Rating Scales for satisfaction and pain. RESULTS Redislocation occurred in 8 cases (23.5%) and subluxation occurred in 13 cases (38.2%) post-surgery. A significant higher number of redislocations and subluxations were seen before 2010 (p = 0.04, p = 0.03). The median postoperative IKDC, Lysholm and Kujala scores for the total group were 54, 76 and 81 respectively. Pre- and postoperative Tegner activity scale were both level 3. Median NRS scores during rest, walking and sports were 1, 3 and 5 respectively. Satisfaction with the procedure was reported as 'excellent' or 'good' by 79% of the patients. CONCLUSION Despite the high overall redislocation rate and increased pain scores, the SST-procedure shows to be a safe procedure in patients with recurrent patellar dislocations based on the cases after 2010. Mid- and long-term results show moderate to good functional outcomes and satisfaction. LEVEL OF EVIDENCE Therapeutic retrospective cohort study, LEVEL III.
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Affiliation(s)
- Raymond Puijk
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands.
| | - Rachid Rassir
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands
| | - Jan K G Louwerens
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands
| | - Inger N Sierevelt
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands.,Specialized Center of Orthopedic Research and Education (SCORE), Xpert Orthopedics, Amsterdam, Laarderhoogtweg 12, The Netherlands
| | - Tjitte de Jong
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands
| | - Peter A Nolte
- Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands
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Agarwalla A, Yao K, Darden C, Gowd AK, Sherman SL, Farr J, Shubin Stein BE, Amin NH, Liu JN. Assessment and Trends of the Methodological Quality of the Top 50 Most Cited Articles on Patellar Instability. Orthop J Sports Med 2021; 9:2325967120972016. [PMID: 33614793 PMCID: PMC7869164 DOI: 10.1177/2325967120972016] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
Background Studies with a low level of evidence (LOE) have dominated the top cited research in many areas of orthopaedics. The wide range of treatment options for patellar instability necessitates an investigation to determine the types of studies that drive clinical practice. Purpose To determine (1) the top 50 most cited articles on patellar instability and (2) the correlation between the number of citations and LOE or methodological quality. Study Design Cross-sectional study. Methods The Scopus and Web of Science databases were assessed to determine the top 50 most cited articles on patellar instability between 1985 and 2019. Bibliographic information, number of citations, and LOE were collected. Methodological quality was calculated using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS). Mean citations and mean citation density (citations per year) were correlated with LOE, MCMS, and MINORS scores. Results Most studies were cadaveric (n = 10; 20.0%), published in the American Journal of Sports Medicine (n = 13; 26.0%), published between 2000 and 2009 (n = 41; 82.0%), and conducted in the United States (n = 17; 34.0%). The mean number of citations and the citation density were 158.61 ± 59.53 (range, 95.5-400.5) and 12.74 ± 5.12, respectively. The mean MCMS and MINORS scores were 59.62 ± 12.58 and 16.24 ± 3.72, respectively. No correlation was seen between mean number of citations or citation density versus LOE. A significant difference was found in the mean LOE of articles published between 1990 and 1999 (5.0 ± 0) versus those published between 2000 and 2009 (3.12 ± 1.38; P = .03) and between 2010 and 2019 (3.00 ± 1.10; P = .01). Conclusion There was a shift in research from anatomy toward outcomes in patellar instability; however, these articles demonstrated low LOE and methodological quality. Higher quality studies are necessary to establish informed standards of management of patellar instability.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Kaisen Yao
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York, USA
| | - Christon Darden
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, New York, USA
| | - Anirudh K Gowd
- Department of Orthopedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Jack Farr
- Cartilage Restoration Center, OrthoIndy, Greenwood, Indiana, USA
| | | | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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Zhang K, Jiang H, Li J, Fu W. Comparison Between Surgical and Nonsurgical Treatment for Primary Patellar Dislocations in Adolescents: A Systematic Review and Meta-analysis of Comparative Studies. Orthop J Sports Med 2020; 8:2325967120946446. [PMID: 33015209 PMCID: PMC7513014 DOI: 10.1177/2325967120946446] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Whether surgical or nonsurgical management is more appropriate for primary
patellar dislocations (PPDs) in adolescents (younger than 18 years) remains
controversial. Purpose: To compare the clinical outcomes of surgical versus nonsurgical treatment for
adolescents and children with PPDs. Study Design: Systematic review; Level of evidence, 3. Methods: There were 2 reviewers who independently searched the PubMed, Embase, Ovid,
and Cochrane databases for English-language studies of randomized controlled
trials (RCTs), quasi-RCTs, and observational studies comparing surgical with
nonsurgical treatment for PPDs. The primary outcomes were redislocations,
the Kujala score, and the Knee injury and Osteoarthritis Outcome Score
(KOOS), and the secondary outcome was subsequent surgery. Results: A total of 6 studies were included in our systematic review and
meta-analysis. Among patients younger than 18 years, surgery was associated
with a lower redislocation rate compared with nonsurgical treatment within 5
years of treatment (risk ratio [RR], 0.58 [95% CI, 0.37-0.91];
P = .02; I2 = 47%) but not beyond 5 years (RR, 0.80 [95% CI, 0.59-1.07];
P = .14; I2 = 34%). However, surgery resulted in worse Kujala and KOOS
scores compared with nonsurgical treatment. Yet, the treatment difference
between the 2 groups tended to decrease over time. Conclusion: The available evidence suggests that for adolescents with PPDs, surgery was
superior to nonsurgical treatment in the short term to reduce the
redislocation rate but resulted in poorer outcomes of knee function based on
the Kujala and KOOS scores. However, the superiority of either surgical or
nonsurgical treatment in adolescents did not appear to persist in the long
term.
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Affiliation(s)
- Kaibo Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Jiang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Fu Z, Zhu Z, Chen H, Zhang S. Surgical treatment is better than non-surgical treatment for primary patellar dislocation: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2020; 140:219-229. [PMID: 31728610 DOI: 10.1007/s00402-019-03308-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND At present, the best treatment for primary patellar dislocation (PPD) has not been unified. Moreover, meta-analyses comparing the non-surgical and surgical treatments of PPD are lacking. Thus, we aimed to compare the clinical efficacy of surgical or non-surgical treatment of PPD. METHODS Randomized controlled studies of surgical and non-surgical treatments of PPD from 1966 to 2018 were retrieved from the following databases: PubMed, EMBASE, Cochrane Library, Wanfang Database, China Knowledge Network, Google Scholar, and Weipu Database. We screened for literature that met the inclusion criteria and extracted useful data for our meta-analysis. RESULTS Nine studies, involving 492 patients, met the inclusion criteria and were analyzed in this study. The recurrence rate of patellar dislocation in the surgical group was lower than that in the non-surgical group (P = 0.04]). Subgroup analysis according to the follow-up time showed that the Kujala score (P < 0.001) and lower recurrence rate of dislocation (P = 0.05) than the non-surgical group in the short term. Subgroup analysis according to surgical year showed that the surgical group get higher Kujala score (P < 0.001) and lower recurrence rate of dislocation (P = 0.01) than the non-surgical group in recent years. CONCLUSION Surgical treatment can provide better clinical results in a short period of time, and patients may achieve good results within 10 years owing to the advances in surgical techniques and instruments. Thus, we recommend surgical treatment as the preferred treatment for primary patellar dislocation.
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Affiliation(s)
- Zhengdao Fu
- Department of Orthopedic Surgery, Hangzhou First People's Hospital, Hangzhou, 310002, China
| | - Zhiqiang Zhu
- Department of Orthopedic Surgery, Hangzhou First People's Hospital, Hangzhou, 310002, China
| | - Haitao Chen
- Department of Orthopedic Surgery, Hangzhou First People's Hospital, Hangzhou, 310002, China
| | - Shiqin Zhang
- Department of Orthopedic Surgery, Hangzhou First People's Hospital, Hangzhou, 310002, China.
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Strickland SM. Editorial Commentary: Medial Patellofemoral Ligament Repair Versus Reconstruction: Still a Question or a Clear Winner? Arthroscopy 2019; 35:2916-2917. [PMID: 31604513 DOI: 10.1016/j.arthro.2019.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 02/02/2023]
Abstract
Controversy persists regarding appropriate treatment of patellar instability. As surgeons move to a more aggressive approach, medial imbrication and medial patellofemoral ligament repair are waning in popularity whereas medial patellofemoral ligament reconstruction has become the standard of care. Techniques vary between surgeons, and consensus remains elusive.
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Pagliazzi G, Napoli F, Previtali D, Filardo G, Zaffagnini S, Candrian C. A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation. Arthroscopy 2019; 35:2469-2481. [PMID: 31395189 DOI: 10.1016/j.arthro.2019.03.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/17/2019] [Accepted: 03/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE II, meta-analysis of level I and level II randomized clinical trials.
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Affiliation(s)
- Gherardo Pagliazzi
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Francesca Napoli
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland; Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
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Shamrock AG, Day MA, Duchman KR, Glass N, Westermann RW. Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review and Meta-analysis. Orthop J Sports Med 2019; 7:2325967119855023. [PMID: 31384615 PMCID: PMC6664654 DOI: 10.1177/2325967119855023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Given the proximity of the medial patellofemoral ligament (MPFL) femoral insertion to the distal femoral physis in skeletally immature patients, multiple techniques for femoral graft fixation have been described. PURPOSE To systematically review the literature and evaluate outcomes and complications following MPFL reconstruction in skeletally immature patients. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A comprehensive literature search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines through use of the PubMed, Embase, and Cochrane Central databases. All original, English-language studies reporting outcomes or complications following MPFL reconstruction in skeletally immature patients were included. Skeletally mature patients were excluded. Data regarding demographics, surgical technique, graft type, outcomes, and complications were recorded. Study quality was assessed by use of the modified Coleman methodology score. Statistical analysis was performed through use of chi-square and weighted mean pooled cohort statistics, where appropriate, with significance set at P < .05. RESULTS 7 studies that entailed 132 MPFL reconstructions (126 patients) met the inclusion criteria. Females comprised 57.9% of the cohort (73 females), and the mean age was 13.2 years (range, 6-17 years). Mean postoperative follow-up was 4.8 years (range, 1.4-10 years). All of the grafts used were autograft, with gracilis tendon (n = 80; 60.6%) being the most common. Methods of femoral fixation included interference screw (n = 52; 39.4%), suture anchor (n = 51; 38.6%), and soft tissue pulley around the medial collateral ligament or adductor tendon (n = 29; 21.9%). Pooled Kujala scores improved from 59.1 to 84.6 after MPFL reconstruction. The total reported complication rate was 25.0% (n = 33) and included 5 redislocations (3.8%) and 15 subluxation events (11.4%). No cases of premature physeal closure were noted, and there were 3 reports of donor site pain (2.3%). Neither autograft choice (P > .804) nor method of femoral fixation (P > .416) influenced recurrent instability or overall complication rates. CONCLUSION These findings suggest that MPFL reconstruction in skeletally immature patients is a viable treatment option, with significant improvement in patient-reported outcomes and redislocation event rates of less than 5% at nearly 5-year follow-up. Further high-quality research is needed to determine optimal graft options and surgical technique while considering recurrent instability, donor site morbidity, and potential injury to the adjacent physis.
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Affiliation(s)
- Alan G. Shamrock
- Department of Orthopaedic Surgery, University of Iowa Hospitals and
Clinics, Iowa City, Iowa, USA
| | - Molly A. Day
- Department of Orthopaedic Surgery, University of Iowa Hospitals and
Clinics, Iowa City, Iowa, USA
| | - Kyle R. Duchman
- Department of Orthopaedic Surgery, University of Iowa Hospitals and
Clinics, Iowa City, Iowa, USA
| | - Natalie Glass
- Department of Orthopaedic Surgery, University of Iowa Hospitals and
Clinics, Iowa City, Iowa, USA
| | - Robert W. Westermann
- Department of Orthopaedic Surgery, University of Iowa Hospitals and
Clinics, Iowa City, Iowa, USA
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Sappey-Marinier E, Sonnery-Cottet B, O'Loughlin P, Ouanezar H, Reina Fernandes L, Kouevidjin B, Thaunat M. Clinical Outcomes and Predictive Factors for Failure With Isolated MPFL Reconstruction for Recurrent Patellar Instability: A Series of 211 Reconstructions With a Minimum Follow-up of 3 Years. Am J Sports Med 2019; 47:1323-1330. [PMID: 31042437 DOI: 10.1177/0363546519838405] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstruction of the medial patellofemoral ligament (MPFL) is widely acknowledged as an integral part of the current therapeutic armamentarium for recurrent patellar instability. The procedure is often performed with concomitant bony procedures, such as distalization of the tibial tuberosity or trochleoplasty in the case of patella alta or high-grade trochlear dysplasia, respectively. At the present time, few studies have evaluated the clinical effectiveness of MPFL reconstruction as an isolated intervention. PURPOSE To report the clinical outcomes of isolated MPFL reconstruction in cases of patellar instability and to identify predictive factors for failure. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective analysis of prospectively collected data was performed, including all patients who had undergone isolated MPFL reconstruction between January 2008 and January 2014. Preoperative assessment included the Kujala score, assessment of patellar tracking ("J-sign"), and radiographic features, such as trochlear dysplasia according to Dejour classification, patellar height with the Caton-Deschamps index (CDI), tibial tubercle-trochlear groove distance, and patellar tilt. The Kujala score was assessed postoperatively. Failure was defined by a postoperative patellar dislocation or surgical revision for recurrent patellar instability. RESULTS A total of 239 MPFL reconstructions were included; 28 patients (11.7%) were uncontactable and considered lost to follow-up. Thus, 211 reconstructions were analyzed with a mean follow-up of 5.8 years (range, 3-9.3 years). The mean age at surgery was 20.6 years (range, 12-48 years), and 55% of patients were male. Twenty-seven percent of patients had a preoperative positive J-sign, and 93% of patients had trochlear dysplasia (A, 47%; B, 25%; C, 15%; D, 6%). The mean CDI was 1.2 (range, 1.0-1.7); mean tibial tubercle-trochlear groove distance, 15 mm (range, 5-30 mm); and mean patellar tilt, 23° (range, 9°-47°). The mean Kujala score improved from 56.1 preoperatively to 88.8 ( P < .001). Ten failures were reported that required surgical revision for recurrent patellar instability (4.7%). Uni- and multivariate analyses highlighted 2 preoperative risk factors for failure: patella alta (CDI ≥1.3; odds ratio, 4.9; P = .02) and preoperative positive J-sign (odds ratio, 3.9; P = .04). CONCLUSION In cases of recurrent patellar instability, isolated MPFL reconstruction would appear to be a safe and efficient surgical procedure with a low failure rate. Preoperative failure risk factors identified in this study were patella alta with a CDI ≥1.3 and a preoperative positive J-sign.
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Affiliation(s)
- Elliot Sappey-Marinier
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Padhraig O'Loughlin
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Herve Ouanezar
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Levi Reina Fernandes
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Biova Kouevidjin
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Groupe Ramsay-Generale de Santé, Lyon, France
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Rosinski A, Chakrabarti M, Gwosdz J, McGahan PJ, Chen JL. Double-Bundle Medial Patellofemoral Ligament Reconstruction With Allograft. Arthrosc Tech 2019; 8:e513-e520. [PMID: 31194129 PMCID: PMC6552203 DOI: 10.1016/j.eats.2019.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/21/2019] [Indexed: 02/03/2023] Open
Abstract
Medial patellofemoral ligament (MPFL) reconstruction is the treatment of choice for recurrent patellofemoral instability. Although attention to MPFL reconstruction in the orthopaedic literature has increased dramatically in recent years, there is no clear consensus on surgical technique, graft option, or method of fixation. Nevertheless, most studies have shown improved pain scores and low rates of recurrent dislocation in patients after surgery. Despite the early success of MPFL reconstruction, complications may occur more frequently than previously appreciated and include patellar fracture, postoperative instability, and loss of flexion. This article describes our technique for double-bundle MPFL reconstruction with an allograft while highlighting certain aspects of the procedure that are critical for achieving favorable outcomes. The main advantages of the technique include strong patellar fixation with suture anchors and anatomic graft placement at the origin and insertion of the native MPFL. In our experience, this method of reconstruction has been safe, reproducible, and effective in the treatment of patients with patellar instability.
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Affiliation(s)
- Alexander Rosinski
- Address correspondence to Alexander Rosinski, M.S., Advanced Orthopaedics and Sports Medicine, 450 Sutter St, Ste 400, San Francisco, CA 94108, U.S.A.
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No Difference in Outcome Between Femoral Soft-Tissue and Screw Graft Fixation for Reconstruction of the Medial Patellofemoral Ligament: A Randomized Controlled Trial. Arthroscopy 2019; 35:1130-1137. [PMID: 30871907 DOI: 10.1016/j.arthro.2018.11.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of the present randomized controlled trial was to compare 2 different medial patellofemoral ligament reconstruction (MPFL-R) techniques that utilize different femoral fixation principles, which could affect subjective clinical outcomes and surgical morbidity. METHODS Sixty patients were randomly assigned to 2 MPFL-R techniques: bone or soft-tissue fixation of the graft at the femoral condyle. Patients had operations performed between 2010 and 2015 at a single center. Indication for surgery was 2 or more patellar dislocations. When the bone fixation technique was used, the gracilis tendon was fixed with the use of an interference screw. When the soft-tissue fixation technique was used, the gracilis tendon was looped around the adductor magnus tendon. Both techniques used patella-graft fixation with drill holes in the medial patellar edge. Clinical outcomes were evaluated by means of Kujala, knee injury and osteoarthritis outcome, and pain scores before the operation and at 1- and 2-year follow-up examinations. Surgical morbidity was evaluated by pain on palpation along the reconstruction site. RESULTS Kujala scores were 88 and 89 for bone and soft-tissue fixation groups, respectively, with no difference between groups (P = .73). No significant differences in knee injury osteoarthritis outcome or pain scores were found. Analysis of surgical morbidity, defined as femoral-based tenderness overlying the fixation site, demonstrated that 13% and 12% of patients had significant tenderness at the reconstruction site after bone and soft-tissue MPFL-R, respectively. No patellar re-dislocations were observed in either group. CONCLUSIONS MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. Surgical morbidity was also similar between patients who had soft-tissue and those who had bone fixation MPFL-R. Soft-tissue femoral graft fixation does not result in inferior clinical outcomes compared with screw fixation, and it can be used safely for MPFL-R.
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A new classification of injury patterns of the medial patellofemoral ligament after acute lateral patella dislocation detected using magnetic resonance imaging studies. Injury 2019; 50:534-540. [PMID: 30466734 DOI: 10.1016/j.injury.2018.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/28/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute lateral patellar dislocation is a very common condition in orthopedics, especially among adolescents and physically active patients. To evaluate distinct medial patellofemoral ligament (MPFL) injury patterns and the associated knee pathology after acute lateral patellar dislocation (ALPD) using magnetic resonance imaging (MRI) studies, which is essential for the development of treatment protocols. MATERIALS AND METHODS MRI images of 74 ALPD patients were taken between January 2015 to December 2016. Images were evaluated using standardized protocols. RESULTS The prevalence of MPFL injury following ALPD was 97.3% (72/74 patients). Among the 72 patients with MPFL, the prevalence of Type Ⅰ injury was 26.4% (19/72). Since only bone marrow edema and a partial tear were showed on MRI of these patients, conservative treatment was given. Tear of the MPFL occurred at the patellar attachment (Type Ⅱa) in 16 patients (16/72, 22.2%), at the middle area of the ligament (Type Ⅱb) in 5 patients (5/72, 6.9%), and at the femoral attachment (Type Ⅱc) in 27 patients (27/72, 37.5%). For Type Ⅱ injuries, all patients had the surgery to reconstruct the MPFL. The prevalence of Type Ⅲ MPFL injury was 6.9% (5/72) after the surgery. CONCLUSION MPFL injury of is a common sequel following ALPD. We assessed the distinct injury pattern and associated pathology of MPFL using MRI studies. A good understanding of the injury pattern and associated knee pathology of MPFL is essential in managing patients with ALPD, especially if surgical intervention is considered.
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Abstract
Compared with skeletally mature patients, skeletally immature patients are at a higher risk of acute traumatic patellar dislocation. Surgical treatment is the standard of care for patients with recurrent instability and requires important and technically challenging physeal considerations. Physeal-sparing medial patellofemoral ligament reconstruction is the treatment of choice for these patients, replacing older nonanatomic extensor mechanism realignment techniques. Implant-mediated guided growth is an important adjunct to correct genu valgum angular deformities that contribute to patellar instability. Patient-specific surgical techniques and proper surgical indications are crucial for successful outcomes.
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Pinheiro Junior LFB, Cenni MHF, Nicolai OP, Gomes LPH, Leal RS, Coelho DGP. Outcomes of medial patellofemoral ligament reconstruction in patients with patella alta. Rev Bras Ortop 2018; 53:570-574. [PMID: 30245996 PMCID: PMC6147778 DOI: 10.1016/j.rboe.2017.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/27/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To compare the clinical outcomes and the results of knee functional scores in patients with normal patellar height and patella alta who underwent isolated medial patellofemoral ligament reconstruction. METHODS A total of 37 knees from 33 patients with recurrent patellar dislocation who underwent isolated medial patellofemoral ligament reconstruction were included. Retrospectively, the postoperative clinical results were compared using the Kujala and Lysholm scores in the group of patients with normal patellar height and in those with patella alta. RESULTS The sample consisted of 37 patients; 16 knees of 14 patients in the group with normal patellar height, 21 knees of 19 patients in the group with patella alta. In the first group, the mean Kujala score was 85.8 and the mean Lysholm score was 85.6. In the second, the mean Kujala score was 78.1 and the mean Lysholm score was 79.7. No significant differences were observed between the groups in relation to the Lysholm (p = 0.296) and Kujala scores (p = 0.181). CONCLUSION Isolated medial patellofemoral ligament reconstruction presented similar results in patients with normal patellar height and patella alta.
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Pinheiro Júnior LFB, Cenni MHF, Nicolai OP, Gomes LPH, Leal RS, Coelho DGP. Resultados da reconstrução isolada do ligamento patelofemoral medial em pacientes com patela alta. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Abstract
PURPOSE OF REVIEW Historically, the standard of care for patients with an acute patella dislocation has been non-operative with the exception being those with a loose body or osteochondral fracture requiring fixation or removal. RECENT FINDINGS Recent literature has brought into question this standard of care approach and defined a higher risk subset of first-time dislocators who may benefit from early operative treatment. In addition, these studies suggest that operative treatment not only reduces the risk of recurrence but may improve outcomes overall and specifically in the pediatric population. Though the "high risk" population of first-time dislocators has been more clearly defined, how we treat them remains controversial. We continue to need more evidence-based guidelines to help us manage who we should be fixing and how we should be fixing them. We currently have several multi-center studies in progress, including one specifically looking at the question of medial patellofemoral ligament reconstruction in first-time pediatric and adolescent dislocators.
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McNeilan RJ, Everhart JS, Mescher PK, Abouljoud M, Magnussen RA, Flanigan DC. Graft Choice in Isolated Medial Patellofemoral Ligament Reconstruction: A Systematic Review With Meta-analysis of Rates of Recurrent Instability and Patient-Reported Outcomes for Autograft, Allograft, and Synthetic Options. Arthroscopy 2018; 34:1340-1354. [PMID: 29366741 DOI: 10.1016/j.arthro.2017.11.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether graft selection or patient age affects the following after isolated medial patellofemoral ligament (MPFL) reconstruction: (1) rates of recurrent instability, (2) rates of postoperative complications (other than instability), and (3) subjective symptom improvement. METHODS A systematic search identified studies reporting outcomes for isolated MPFL reconstruction. Rates of recurrent instability, subjective Kujala knee function scores, and complications were tabulated. Symptom improvement was defined as change in Kujala score (preoperative evaluation to final follow-up). RESULTS Forty-five studies were included with 27 documented cases of recurrent instability among 1,504 patients (1.8%); instability rates ranged from 0% to 20.0% overall; among autograft in adults, 0% to 11.1% (1.4%, 18/1,260); among autograft in adolescents, 0% to 20% (10.0%, 8/80); among allograft, 0% (0/65 cases); and among synthetic, 0% to 3.3% (1.3%, 1/76). Among autograft choices in adults, rates of recurrent instability were low; recurrence with gracilis ranged from 0% to 11.1% (0.9%, 1/116); with semitendinosus, 0% to 6.3% (0.6%, 4/676); with quad or patellar tendon, 0% (0/65); and with adductor tendon, 5.6% to 8.3% (6.7%, 2/30). Complication rates ranged from 0% to 34.4%. All included studies reported significant improvement in Kujala scores after surgery (P < .01). There was significant heterogeneity in effect size and evidence of reporting bias among small studies, precluding reliable pooled analysis of treatment effect. CONCLUSIONS Autograft is not superior to allograft or synthetic grafts for isolated reconstruction of the MPFL, and rates of recurrent instability are generally low. Isolated MPFL reconstruction can provide significant symptom relief regardless of graft selection, although there is a bias toward reporting better than expected results among smaller studies. Pediatric patients and patients treated with adductor tendon autograft have higher recurrent instability rates. While caution should be used in making definitive recommendations secondary to the small number of allograft and synthetic studies, selection of graft type based on surgeon preference, comfort, and prior experience remains appropriate. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Ryan J McNeilan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Joshua S Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Patrick K Mescher
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Moneer Abouljoud
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.; Cartilage Restoration Program, The Ohio State University, Columbus, Ohio, U.S.A..
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Patellar tracking after isolated medial patellofemoral ligament reconstruction: dynamic evaluation using computed tomography. Knee Surg Sports Traumatol Arthrosc 2017; 25:3197-3205. [PMID: 27544273 DOI: 10.1007/s00167-016-4284-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 08/09/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction offers good clinical results with a very low rate of instability recurrence. However, its in vivo effect on patellar tracking is not clearly known. The aim of this study is to investigate the effects of MPFL reconstruction on patellar tracking using dynamic 320-detector-row CT. METHODS Ten patients with patellofemoral instability referred to isolated MPFL reconstruction surgery were selected and subjected to dynamic CT before and ≥6 months after surgery. Patellar tilt angles and shift distance were analysed using computer software specifically designed for this purpose. Kujala and Tegner scores were applied, and the radiation of the CTs was recorded. Two protocols for imaging acquisition were compared: a tube potential of 80 kV and 50 mA versus a tube potential of 120 kV and 100 mA, both with a slice thickness of 0.5 mm and an acquisition duration of 10 s. RESULTS There were no changes in patellar tracking after MPFL reconstruction. There was no instability relapse. Clinical scores improved from a mean of 51.9 (±15.6)-74.2 (±20.9) on the Kujala scale (p = 0.011) and from a median of 2 (range 0-4) to 4 (range 1-6) on the Tegner scale (p = 0.017). The imaging protocols produced a dose-length product (DLP) of 254 versus 1617 mGycm and a radiation effective estimated dose of 0.2 versus 1.3 mSv, respectively. Both protocols allowed the analysis of the studied parameters without loss of precision. CONCLUSIONS Reconstruction of the MPFL produced no improvement in patellar tilt or shift in the population studied. The low-radiation protocol was equally effective in measuring changes in patellar tracking and is recommended. Although the procedure successfully stabilized the patella, knee surgeons should not expect patellar shift and tilt correction when performing isolated patellofemoral ligament reconstruction in patients with recurrent patellar instability. LEVEL OF EVIDENCE IV.
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Calapodopulos CJ, Nogueira MC, Eustáquio JMJ, Calapodopulos Júnior CJ, Rodrigues OA. Reconstrução do ligamento patelofemoral medial com enxerto autólogo do tendão quadricipital no tratamento da luxação recidivante da patela. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Calapodopulos CJ, Nogueira MC, Eustáquio JMJ, Calapodopulos Júnior CJ, Rodrigues OA. Reconstruction of the medial patellofemoral ligament using autologous graft from quadriceps tendon to treat recurrent patellar dislocation. Rev Bras Ortop 2016; 51:187-93. [PMID: 27069888 PMCID: PMC4811995 DOI: 10.1016/j.rboe.2016.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/29/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy of the surgical technique using the quadriceps tendon as a graft in static reconstruction of the medial patellofemoral ligament. METHODS This was a prospective case series study in which the participants were 22 patients with a diagnosis of recurrent patellar dislocation without any other anatomical alterations that required surgical treatment. The functional results from the technique were evaluated using clinical data and the Lysholm questionnaire, one year after the operation. RESULTS It was observed that the patients were predominantly female (86%) and under 21 years of age (73%), just like in the literature. At the first annual return after the surgery, there was no significant pain on medium efforts, no loss of range of motion and a positive apprehension test. According to the questionnaire used, the results were graded as good. The patients who reported having severe pain on greater effort were involved in employment-related legal disputes. CONCLUSION This technique showed low morbidity and good functional results over the short term.
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Affiliation(s)
- Constantino Jorge Calapodopulos
- Department of Orthopedics and Traumatology, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil
- Department of Orthopedics and Traumatology, Universidade de Uberaba (UNIUBE), Uberaba, MG, Brazil
| | | | | | | | - Oreston Alves Rodrigues
- Department of Orthopedics and Traumatology, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil
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Pinheiro Júnior LFB, Cenni MHF, Nicolai OP, Carneiro GGB, de Andrade RC, de Moraes VV. Correlação clínico‐radiográfica do ponto de inserção femoral do enxerto na reconstrução do ligamento patelofemoral medial. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2015.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Pinheiro Júnior LFB, Cenni MHF, Nicolai OP, Carneiro GGB, de Andrade RC, de Moraes VV. Clinical-radiographic correlation of the femoral insertion point of the graft in reconstruction of the medial patellofemoral ligament. Rev Bras Ortop 2015; 50:700-4. [PMID: 27218083 PMCID: PMC4867915 DOI: 10.1016/j.rboe.2015.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 10/14/2014] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To analyze the radiographic positioning of the femoral tunnel and correlate this with the postoperative clinical results among patients undergoing reconstruction of the medial patellofemoral ligament (MPFL) alone. METHOD This was a retrospective study in which 30 knees of 26 patients with recurrent dislocation of the patella that underwent MPFL reconstruction were evaluated. The femoral insertion point of the graft and the postoperative clinical condition were analyzed and correlated using the Kujala and Lysholm scales. RESULTS 22 knees presented a femoral tunnel in the anatomical area (group A) and 8 outside of this location (group B). In group A, the mean score on the Kujala scale was 89.68 points and on the Lysholm scale was 92.45 points. In group B, the mean score on the Kujala scale was 84.75 points and on the Lysholm scale was 92 points. The difference between the means was not significant on either of the two scales. CONCLUSION Correlation with the clinical results did not show any difference in relation to the positioning of the femoral insertion of the graft.
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Albuquerque RPE, Félix dos Santos Neto J, Albuquerque MIPE, Giordano V, Pecegueiro do Amaral N. Fixation of an osteochondral fragment after acute patellar dislocation in an immature skeleton. Rev Bras Ortop 2014; 49:202-5. [PMID: 26229800 PMCID: PMC4511747 DOI: 10.1016/j.rboe.2014.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/12/2013] [Indexed: 11/29/2022] Open
Abstract
Fixation of an osteochondral fracture after acute patellar dislocation is an infrequent form of treatment. Likewise, the location of this fragment in the lateral region of the lateral femoral condyle, functioning as a free body, is uncommon. The aim of this study was to present a case of osteochondral fracture of the patella at an unusual site, along with the therapy used and the clinical follow-up.
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Affiliation(s)
| | | | | | - Vincenzo Giordano
- Orthopedics Service, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
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Albuquerque RPE, Félix dos Santos Neto J, Albuquerque MIPE, Giordano V, Pecegueiro do Amaral N. Fixação do fragmento osteocondral após luxação aguda da patela no esqueleto imaturo. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2014.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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