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Miao M, Cai H, Wang Z, Hu L, Bian J, Cai H. Suprapatellar pouch effusion is associated with an increased risk of neglected osteochondral fractures in primary acute traumatic patellar dislocation: a consecutive series of 113 children. J Orthop Surg Res 2023; 18:627. [PMID: 37633950 PMCID: PMC10464257 DOI: 10.1186/s13018-023-04130-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the risk factors of neglected osteochondral fractures in primary acute traumatic patellar dislocation in the pediatric population. METHODS A total of 113 patients with primary acute traumatic patellar dislocation for whom coincident osteochondral fractures could not be confirmed by X-ray examination at initial diagnosis between January 2010 and February 2022 were retrospectively analyzed. Medical history, physical examination, and radiographic images were recorded in detail. The greatest dimension of the suprapatellar pouch (SP) effusion on radiograph was measured. Computed tomography and magnetic resonance imaging were used to confirm the presence of neglected osteochondral fractures and measure the fragment size. Potential risk factors were calculated and correlated with reference to the neglected osteochondral fractures and fragment size using multivariate linear regression analysis. RESULTS Weight, walking ability, effusion grade, and SP measurement had a significant correlation with neglected osteochondral fractures in primary acute traumatic patellar dislocation (p = 0.046; p < 0.001; p = 0.048; p < 0.001). The cutoff point was 53.5 kg for weight and 18.45 mm for SP measurement. In the neglected fractures group, SP measurement was statistically significant with larger fragment size (beta value = 0.457; p < 0.001), and the cutoff point was 26.2 mm. CONCLUSIONS SP effusion is not only associated with an increased risk of neglected osteochondral fractures in primary acute traumatic patellar dislocation but also with larger fragment size. Knee radiograph, medical history, and physical examination can predict the need for further imaging examination and even surgery in primary acute traumatic patellar dislocation.
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Affiliation(s)
- Mingyuan Miao
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haoqi Cai
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhigang Wang
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liwei Hu
- Department of Radiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxia Bian
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haiqing Cai
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Ji G, Zhou J, Gao J, Bai W, Wang F. Medial Plication Using an Arthroscopic All-Inside Technique for Treatment of Patellar Instability in Adolescents. J Knee Surg 2022; 35:1434-9. [PMID: 33652479 DOI: 10.1055/s-0041-1723978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to present a medial plication using an arthroscopic all-inside technique for the treatment of patellar instability in adolescents. From July 2009 to June 2012, 19 patients with acute patellar dislocation were operated by this technique. Of these patients, follow-up was available in 17 patients at an average of 3 years (range: 1.5-4 years). At the follow-up, we evaluated the patients with physical examinations, radiographs, computed tomography scan, as well as the Lysholm and Kujala scoring scales. No recurrence of patellar instability has been found. The recovery of knee mobilization resulted to be good. We think this could be a valid technique to treat patellar instability in adolescents with less associated morbidity and good cosmetic results.
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Cook CE, Saad M, Tucker CJ, Min KS, Westrick RB, Rhon DI. Differences in Outcomes between Patellar Dislocations Managed in Emergent versus Non-Emergent Care Settings. J Knee Surg 2022; 35:1056-1062. [PMID: 35820435 DOI: 10.1055/s-0042-1749079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellar dislocations occur at a much higher rate in military than civilian populations. Past population-level studies have shown that surgical management is as good as or superior to conservative care and may reduce future reoccurrences. Although in acute cases and in civilian clinics, patellar dislocations are usually managed first in an emergent care setting, previous work suggests this can lead to increased costs. This study compared differences in downstream care type and intensity of services based on whether initial care occurred in emergent or non-emergent care settings. In our sample of 1,523 Military Health System (MHS) beneficiaries with patellar dislocation and 2-year follow-up, we found non-significant differences in costs, intensity of services, and rates of surgical repair regardless of whether the patient was initially seen in an emergent versus non-emergent care setting. Although we found significant increases in the use of imaging, patellar dislocation-related medical visits, and frequency of closed treatment approaches in emergent care settings, these values were very small and likely not clinically significant. These findings, which included all the patellar dislocations reported across the entire MHS in a 24-month period, suggest that neither emergent nor non-emergent care settings are likely to influence the long-term care received by the individual.
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Affiliation(s)
- Chad E Cook
- Department of Orthopaedics, Duke University, Durham, North Carolina.,Department of Population Health Sciences, Durham, North Carolina.,Division of Musculoskeletal and Surgical Sciences, Duke Clinical Research Institute, Durham, North Carolina
| | - Mohammad Saad
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Christopher J Tucker
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland
| | - Kyong S Min
- Department of Orthopedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii
| | - Richard B Westrick
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Daniel I Rhon
- Department of Orthopedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii.,Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts
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Qiu RY, Fitzpatrick DWD, Cohen D, Kay J, Almasri M, de Sa DL. MRI as the optimal imaging modality for assessment and management of osteochondral fractures and loose bodies following traumatic patellar dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022. [PMID: 35796753 DOI: 10.1007/s00167-022-07043-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/09/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To assess the imaging modalities used for diagnosis, as well as the management decisions of patients with osteochondral fractures (OCF) and loose bodies following traumatic patellar dislocation. METHODS According to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA), MEDLINE, EMBASE, Web of Science, and PubMed were searched for results from January 1, 2000, to May 18, 2021, in two subsequent searches for English language studies that presented data on traumatic patellar dislocation. Quality of selected papers was assessed using the Methodological Index for Non-Randomised Studies (MINORS) and the Risk of Bias (RoB) 2.0 protocol. Results were qualitatively synthesised, and descriptive statistics were calculated. RESULTS Forty studies totalling 3074 patients (1407 females) were included for the analysis. The mean age was 18.9 years (range 0-69). The population included 2446 first-time dislocations. The imaging modalities used were: 71.1% MRI, 52.6% plain radiography, 12.1% CT, and 0.68% ultrasound. In the 25 studies that reported the number of OCF, a total of 38.3% of patients were found to have OCF. 43.3% of patients with a first-time dislocation, and 34.7% of patients with previous dislocations, had at least one OCF. In the included paediatric studies (maximum age ≤ 18), the presence of OCF was detected by plain radiography in 10.1% of patients, MRI in 76.6% of patients, and CT in 89.5% of patients. For management of an OCF, the surgical options include fixation for larger pieces, excision for smaller pieces, and conservative management on a case-by-case basis. CONCLUSIONS Based on the current available evidence, assessment and management of patellar dislocations and subsequent OCFs vary, with radiography and MRI as the main imaging modalities on presentation and particular benefit for MRI in the paediatric population. Findings from this study suggest the highest rate of OCF detection with MRI, and thus, surgeons should consider routinely ordering an MRI in patients with first-time patellar dislocation. Regarding management of OCFs, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. Few studies choose conservative management of OCFs due to later requirements for surgical management. Future work should focus on large, high-quality studies, and implementation of randomised control trials to form guidelines for imaging patellar dislocations and management of OCFs. LEVEL OF EVIDENCE Level IV.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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LeBrun DG, Nwachukwu BU, Buza SS, Gruber S, Marmor WA, Dennis ER, Shubin Stein BE. Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions. Arthroscopy 2022; 38:1252-1263.e3. [PMID: 34619304 DOI: 10.1016/j.arthro.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions. METHODS A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm2). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions. RESULTS From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective. CONCLUSIONS In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results. LEVEL OF EVIDENCE III, economic and decision analysis.
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Galvão PHSAF, Marques DS, Gracitelli GC, Ferreira MDC, Kubota MS, Franciozi CEDS. Portuguese Translation and Cross-Cultural Adaption of the Banff Patella Instability Instrument. Rev Bras Ortop 2021; 56:747-760. [PMID: 34900103 PMCID: PMC8651449 DOI: 10.1055/s-0040-1721840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/16/2020] [Indexed: 11/21/2022] Open
Abstract
Objective
To translate into Brazilian Portuguese and to cross-culturally adapt the Banff Questionnaire for Patellar Instability.
Methods
The translation and cross-cultural adaptation followed the linguistic validation process proposed by international guidelines, which consists of six steps: translation, synthesis, back-translation, review by an expert committee, pretest, and final report presentation to the authors of the original questionnaire. Literate patients with recurrent patellar instability, older than 12 years of age, who signed the informed consent form or had it signed by a legal guardian were included in the study. Patients with neurological or systemic comorbidities were excluded from the study.
Results
A total of 62 patients (18 males and 44 females) were included in the study. Discrepancies observed during the processes of translation and harmonization of the back-translations were modified with no need for reformulation. No pretest version replacements were required.
Conclusion
The Banff Questionnaire for Patellar Instability has been successfully translated and cross-culturally adapted into Brazilian Portuguese, so it can be used to assess patients with patellar instability who speak this language.
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Affiliation(s)
| | - Dayane Screpante Marques
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Guilherme Conforto Gracitelli
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Marcelo Seiji Kubota
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Li LT, Bokshan SL, Lemme NJ, Testa EJ, Owens BD, Cruz AI. Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population. Arthrosc Sports Med Rehabil 2021; 3:e1279-e1286. [PMID: 34712964 PMCID: PMC8527270 DOI: 10.1016/j.asmr.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/31/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. Methods The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. Results There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). Conclusions Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Lambert T. Li
- Address correspondence to Lambert T. Li, B.A., Department of Orthopaedic Surgery, Sports Injury Laboratory, Brown University, Warren Alpert School of Medicine, 1 Kettle Point Ave., Providence, RI 02906, U.S.A.
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Ling DI, Brady JM, Arendt E, Tompkins M, Agel J, Askenberger M, Balcarek P, Parikh S, Shubin Stein BE. Development of a Multivariable Model Based on Individual Risk Factors for Recurrent Lateral Patellar Dislocation. J Bone Joint Surg Am 2021; 103:586-592. [PMID: 33787553 DOI: 10.2106/jbjs.20.00020] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative treatment after first-time patellar dislocation is the standard of care. There is evidence that certain patients may be at high risk for recurrent instability. The aim of this study was to develop a multivariable model to guide management of patients based on their individual risk of recurrent dislocation. METHODS A multivariable model was developed using 291 patients from 4 institutions to identify which patients were at higher risk for recurrent patellar dislocation within 2 years. This model was informed by a univariable logistic regression model developed to test factors based on the patient's history, physical examination, and imaging. The discriminatory ability of the model to classify who will or will not have a recurrent dislocation was measured using the area under the receiver operating characteristic curve (AUC). RESULTS Age, a history of a contralateral patellar dislocation, skeletal immaturity, lateral patellar tilt, tibial tubercle-trochlear groove (TT-TG) distance, Insall-Salvati ratio, and trochlear dysplasia were the most important factors for recurrent patellar dislocation. Sex, mechanism of injury, Caton-Deschamps ratio, sulcus angle, inclination angle, and facet ratio were not factors for recurrent dislocation. The overall AUC for the multivariable model was 71% (95% confidence interval [CI]: 64.7% to 76.6%). CONCLUSIONS Optimizing the management of lateral patellar dislocation will improve short-term disability from the dislocation and reduce the long-term risk of patellofemoral arthritis from repeated chondral injury. This multivariable model can identify patients who are at high risk for recurrent dislocation and would be good candidates for early operative treatment. Further validation of this model in a prospective cohort of patients will inform whether it can be used to determine the optimal treatment plan for patients presenting with an initial patellar dislocation. Until validation of the model is done with new patients, it should not be used in clinical practice. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daphne I Ling
- Hospital for Special Surgery, New York, NY.,Weill Cornell Medical College, New York, NY
| | | | | | | | - Julie Agel
- University of Minnesota, Minneapolis, Minnesota
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Xu Z, Zhang H, Guo M, Wen Z, Zhang J, Zhou A. Malalignment sign on knee magnetic resonance imaging: a new predictor for excessive femoral anteversion in patients with patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2021; 29:1075-82. [PMID: 32514841 DOI: 10.1007/s00167-020-06080-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the clinical relevance of the newly identified malalignment sign in predicting excessive femoral anteversion in patients with patellar dislocations. METHODS A total of 55 patients with patellar dislocation who underwent surgical treatment between 2016 and 2019 were included in this study. Femoral anteversion, tibial torsion, and the femorotibial index were measured via a CT scan. The malalignment sign on the knee MRI was defined as a malalignment between the lateral side of the intercondylar fossa of the femur and the lateral intercondylar eminence of the tibial plateau. RESULTS A positive malalignment sign was observed in 36 of the 55 patients. Increased femoral anteversion was significantly correlated with the number of frames with a positive malalignment sign (r = 0.511, P < 0.001). The value of femoral anteversion was significantly greater in the group with a positive malalignment sign (P = 0.02). For a femoral anteversion value of 32°, the sensitivity and specificity of the malalignment sign reached the maximal level of 89.5% and 47.2%, respectively. CONCLUSION Increased femoral anteversion correlated significantly with a positive malalignment sign on knee MRI. However, tibial torsion did not affect the malalignment sign. A positive malalignment sign is evidence for femoral derotation osteotomy. LEVEL OF EVIDENCE Level IV.
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Abstract
PURPOSE OF REVIEW The topic of acute patella dislocations is controversial. Discussions revolve around which individuals need early surgery, identification of risk factors, and rehabilitation protocol. The purpose of this review is to discuss the current recommendations for non-operative and/or operative management of first-time dislocators. RECENT FINDINGS Recent studies have made it clear that not all patellar dislocations are the same, not all patients do well with conservative treatment, and risk stratification can identify individuals at high risk of recurrence who would benefit from early surgical intervention. Risk factors that have been identified include younger age, skeletally immature, contralateral instability, trochlear dysplasia, patella alta, increased tibial tubercle-trochlear groove distance, and increased patella tilt. The PAPI (Pediatric and Adolescent Patellar Instability) RCT study and JUPITER (Justifying Patellar Instability Treatment by Early Results) prospective cohort study have been carefully developed, are under way, and will provide further guidance. In summary, the management of acute patellar dislocations is evolving. Surgery for patients with osteochondral loose bodies should include fixation as well as soft tissue stabilization. The standard of care for patients with an acute patellar dislocation without osteochondral loose bodies or fracture is non-operative treatment. However, imaging for all first-time dislocators is indicated to stratify risks and determine risk profile. If an individual is at high risk, soft tissue stabilization may be considered. Still, most patients will be treated non-operatively.
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Affiliation(s)
- Joseph M Rund
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Betina B Hinckel
- Oakland University, Rochester, MI, USA
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA, USA.
- , Redwood City, USA.
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Hinckel BB, Baumann CA, Ejnisman L, Cavinatto LM, Martusiewicz A, Tanaka MJ, Tompkins M, Sherman SL, Chahla JA, Frank R, Yamamoto GL, Bicos J, Arendt L, Fithian D, Farr J. Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00083. [PMID: 33986224 PMCID: PMC7537824 DOI: 10.5435/jaaosglobal-d-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
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Affiliation(s)
- Betina B Hinckel
- From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Adjei J, Nwachukwu BU, Zhang Y, Do HT, Green DW, Dodwell ER, Fabricant PD. Health State Utilities in Children and Adolescents With Osteochondritis Dissecans of the Knee. Orthop J Sports Med 2019; 7:2325967119886591. [PMID: 31840031 PMCID: PMC6896139 DOI: 10.1177/2325967119886591] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The impact of osteochondritis dissecans (OCD) lesions of the knee on a child’s health-related quality of life has not previously been quantified. Preference-based health utility assessment allows patients to assign quality-of-life valuations (utilities) to different health states and conditions. Purpose: To determine (1) patient-reported utility scores for health states associated with pediatric OCD lesions of the knee and (2) whether these scores are associated with patient demographics or disease severity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Children, adolescents, and young adults being treated for OCD of the knee were interviewed to assess utilities for each of the 6 health states commonly encountered in the treatment of OCD: (1) symptomatic lesion, (2) nonoperative rehabilitation, (3) postoperative rehabilitation, (4) intermediate treatment success, (5) early degenerative knee changes, and (6) successful treatment (asymptomatic). Patients were asked to assign health utilities to each state using a standardized feeling thermometer (scale, 0-100), which were converted to a health state utility (scale, 0-1 [1 = perfect health]). Utilities were reported with descriptive statistics, and comparative analyses were performed to test whether assignments were associated with patient age, sex, or whether the OCD lesion required surgical intervention. Results: A total of 100 participants treated or undergoing treatment for OCD were prospectively enrolled; 74% were male (n = 74). The median age at the time of survey was 15 years (interquartile range, 13-16.5 years). Utility scores were as follows: symptomatic OCD lesion, 0.15; nonoperative rehabilitation, 0.30; postoperative rehabilitation, 0.30; early degenerative changes, 0.58; intermediate treatment success, 0.65; and successful treatment, 1.0. Utility scores were not associated with age, sex, or whether the participant underwent surgical treatment for the OCD lesion. Conclusion: The current study quantified patient-reported utilities for 6 OCD lesion health states, which may be used for future health-related quality of life, decision analysis, and quality/safety/value studies. These utility scores were stable and not affected by patient age, sex, or treatment strategy.
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Affiliation(s)
- Joshua Adjei
- Hospital for Special Surgery, New York, New York, USA
| | | | - Yi Zhang
- Hospital for Special Surgery, New York, New York, USA
| | - Huong T Do
- Hospital for Special Surgery, New York, New York, USA
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Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction has become a well-accepted procedure for recurrent patellofemoral instability. Despite a growing volume of research assessing surgical results, the relationship of age and sex to outcomes after MPFL reconstruction surgery is unclear. PURPOSE To investigate whether age at the time of surgery or sex influenced patient-reported quality of life and clinical outcome after MPFL reconstruction for recurrent lateral patellofemoral instability. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between January 2010 and May 2016, 328 patients underwent primary patellofemoral stabilization. Demographic and clinical data were collected preoperatively. Patients completed the Banff Patellofemoral Instability Instrument (BPII) at the pre- and postoperative visits and were assessed clinically at 12 and 24 months. To assess the effects of age at surgery and sex on BPII, multiple linear regression models were fit predicting BPII at 12 and 24 months. An unadjusted regression was applied with the predictors being age at the time of surgery and sex. A second regression model was applied adjusting for age at first dislocation, grade of trochlear dysplasia, knee hyperextension, and the WARPS/STAID score-a measure of the risky patellofemoral instability characteristics of the patient. RESULTS Of 328 patients, 298 (91%) had complete data and minimum 12-month BPII scores available for analysis. There were 11 redislocations in the cohort (3.4%), all in female patients. When stratified by sex, baseline characteristics were not statistically different except for higher age at first dislocation ( P = .022) as well as higher WARPS/STAID scores ( P = .006) for males. Age at the time of surgery was statistically significant for each postoperative follow-up, with lower BPII scores apparent for each 10-year increase in age at the time of surgery. In the adjusted model, the WARPS/STAID score was significantly associated with the preoperative BPII score. For the 24-month postoperative BPII scores, age at time of surgery and preoperative WARPS/STAID score were both significant. Lower BPII scores were apparent for each 10-year increase in age at the time of surgery, as well as for lower scores on the WARPS/STAID classification. CONCLUSION This study demonstrated that when adjusted for risky pathoanatomy, neither age at first dislocation nor sex influences patient-reported quality of life outcomes after MPFL reconstruction. Age at the time of surgery was correlated with outcome, with lower BPII scores apparent for each 10-year increase in age at the time of MPFL reconstruction.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine, Banff, Alberta, Canada.,Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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16
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Erickson BJ, Nguyen J, Gasik K, Gruber S, Brady J, Shubin Stein BE. Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Regardless of Tibial Tubercle-Trochlear Groove Distance and Patellar Height: Outcomes at 1 and 2 Years. Am J Sports Med 2019; 47:1331-1337. [PMID: 30986090 DOI: 10.1177/0363546519835800] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear which patients with recurrent patellar instability require a bony procedure in addition to medial patellofemoral ligament (MPFL) reconstruction. PURPOSE To report 1- and 2-year outcomes of patients after isolated MPFL reconstruction performed for patellar instability regardless of patellar height, tibial tubercle-trochlear groove (TT-TG) distance, or trochlear dysplasia. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients with recurrent patellar instability and without significant unloadable chondral defects (Outerbridge grade IV), cartilage defects (especially inferior/lateral patella), previous failed surgery, or pain >50% as their chief complaint were prospectively enrolled beginning March 2014. All patients underwent primary, unilateral, isolated MPFL reconstruction regardless of concomitant bony pathology for treatment of recurrent patellar instability. Information on recurrent subjective instability, dislocations, ability to return to sport (RTS), and outcome scores was recorded at 1 and 2 years. TT-TG distance, patellar height (with the Caton-Deschamps index), and trochlear depth were measured. RESULTS Ninety patients (77% female; mean ± SD age, 19.4 ± 5.6 years) underwent MPFL reconstruction between March 2014 and August 2017: 72 (80%) reached 1-year follow-up, and 47 (52.2%) reached 2-year follow-up (mean follow-up, 2.2 years). Mean TT-TG distance was 14.7 ± 5.4 mm (range, -2.2 to 26.8 mm); mean patellar height, 1.2 ± 0.11 mm (range, 0.89-1.45 mm); and mean trochlear depth, 1.8 ± 1.4 mm (range, 0.05-6.85 mm). Ninety-six percent of patients at 1 year and 100% at 2 years had no self-reported patellofemoral instability; 1 patient experienced a redislocation at 3.5 years. RTS rates at 1 and 2 years were 90% and 88%, respectively. Mean time to RTS was 8.8 months. All patients had clinically and statistically significant improvement in mean Knee injury and Osteoarthritis Outcome Score-Quality of Life (32.7 to 72.0, P < .001), mean International Knee Documentation Committee subjective form (51.4 to 82.6, P < .001), and mean Kujala score (62.2 to 89.5, P < .001). No difference existed between 1- and 2-year outcome scores (all P > .05). CONCLUSION At early follow-up of 1 and 2 years, isolated MPFL reconstruction is an effective treatment for patellar instability and provides significant improvements in outcome scores with a low redislocation/instability rate regardless of bony pathologies, including TT-TG distance, Caton-Deschamps index, and trochlear dysplasia. Future data from this cohort will be used to assess long-term outcomes.
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Affiliation(s)
| | - Joseph Nguyen
- Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA
| | - Katelyn Gasik
- Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA
| | - Simone Gruber
- Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA
| | - Jacqueline Brady
- Division of Orthopaedic Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Beth E Shubin Stein
- Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA
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Paoli AR, Gold HT, Mahure SA, Mai DH, Agten CA, Rokito AS, Virk MS. Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis. Arthroscopy 2018; 34:2019-29. [PMID: 29653794 DOI: 10.1016/j.arthro.2018.01.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear. METHODS A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness. RESULTS Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644. CONCLUSIONS When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. LEVEL OF EVIDENCE Level III, economic decision analysis.
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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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Kelly DM, VanderHave K, Martus JE. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2018; 100:348-354. [PMID: 29462042 DOI: 10.2106/jbjs.17.01139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Kelly VanderHave
- Carolinas HealthCare System and Levine Children's Hospital, Charlotte, North Carolina
| | - Jeffrey E Martus
- Vanderbilt Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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20
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Abstract
BACKGROUND Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the literature, highlighting recent updates on sports-related knee injuries in the pediatric athlete. We specifically examined literature on tibial spine fractures, osteochondritis dissecans (OCD) of the knee, and patellar instability. Because of the volume of literature on the subject, pediatric, and adolescent anterior cruciate ligament injuries were not included in this review. METHODS An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric: tibial spine fractures, patellar instability, and osteochondritis dissecans (OCD). Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics. RESULTS A total of 31 articles were deemed to have contributed significant findings to the literature: 5 tibial spine, 17 patellar instability, and 9 OCD. The level of evidence for most studies was either level III or IV. CONCLUSIONS The optimal treatment for tibial spine fractures remains controversial. The evaluation of risk factors for recurrent patellar instability is important in determining the optimal treatment strategy following first-time patellar dislocation. Future multicenter studies on pediatric OCD have the potential to further understanding of this difficult problem. High-level, comparative outcomes research on a variety of pediatric sports related injuries is lacking and this review may help inform topics for future study. LEVEL OF EVIDENCE Level IV-literature review.
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