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Song YF, Wang HJ, Yan X, Yuan FZ, Xu BB, Chen YR, Ye J, Fan BS, Yu JK. Tibial Tubercle Osteotomy May Not Provide Additional Benefit in Treating Patellar Dislocation With Increased Tibial Tuberosity-Trochlear Groove Distance: A Systematic Review. Arthroscopy 2021; 37:1670-1679.e1. [PMID: 33359817 DOI: 10.1016/j.arthro.2020.12.210] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the indications and outcomes of medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tubercle osteotomy (TTO) in treating recurrent or habitual patellar dislocation with an increased tibial tuberosity-trochlear groove (TT-TG) distance. METHODS We performed a literature search of the established medical databases Cochrane Central, PubMed-MEDLINE, EMBASE, and Web of Science. The inclusion criteria were as follows: skeletally mature patients with recurrent or habitual patellar dislocation and an increased TT-TG distance, treatment with MPFLR combined with a TTO procedure or isolated MPFLR, and reporting of clinical outcomes and complications. Each study was assessed for quality and the level of evidence. The general characteristics, indications, surgical techniques, TT-TG distance, clinical results, imaging evaluation findings, and complications of each study were recorded. RESULTS Nine studies consisting of 288 knees met the inclusion criteria. The average Coleman score was 71.56 (range, 55-83). The threshold for an increased TT-TG distance ranged from 16 to 20 mm in the included studies. Similar good postoperative outcomes were reported in patients with an increased TT-TG distance treated with MPFLR with versus without a TTO procedure. The mean postoperative Lysholm score ranged from 75.0 to 94.7 (I2 = 87.6%) in the isolated MPFLR group and from 85.0 to 87.6 (I2 = 16.3%) in the TTO-with-MPFLR group. Similar postoperative congruence angles were reported in both groups. The postoperative redislocation rate ranged from 0% to 4.2% in the TTO-with-MPFLR group, and no redislocation was found in the isolated MPFLR group. The postoperative apprehension sign was only reported in isolated MPFLR patients. CONCLUSIONS The outcomes of MPFLR with or without TTO to treat recurrent or habitual patellar dislocation with an increased TT-TG distance appeared similar. However, this study was limited by the considerable heterogeneity, variety of techniques, variety of TT-TG distances, and variability in patella alta and trochlear dysplasia among the included studies. LEVEL OF EVIDENCE Level IV, systematic review of Level II to IV studies.
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Affiliation(s)
- Yi-Fan Song
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Hai-Jun Wang
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xin Yan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Fu-Zhen Yuan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Bing-Bing Xu
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - You-Rong Chen
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Jing Ye
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Bao-Shi Fan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Jia-Kuo Yu
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China.
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102
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Editorial Commentary: Treating Patients With Recurrent Patellar Instability With an Individualized, Anatomic Approach Is Needed: Learn From the Anterior Cruciate Ligament. Arthroscopy 2021; 37:1680-1682. [PMID: 33896516 DOI: 10.1016/j.arthro.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 02/02/2023]
Abstract
Treatment algorithms for recurrent patellofemoral instability have evolved over time. Early treatment techniques focusing specifically on pain have been replaced by evidence-based and anatomically appropriate procedures such as ligament reconstruction, osteotomies, and trochleoplasty. Bony and soft-tissue factors contribute to recurrent patellofemoral instability, but the exact indications for soft-tissue, bony, and combined procedures remain controversial. Personally, I am much more likely to combine tibial tubercle osteotomy with medial patellofemoral ligament reconstruction in a patient with trochlear dysplasia, patella alta, and a large J-sign (in addition to an elevated tibial tubercle to trochlear groove distance). As in cases of anterior cruciate ligament injury, in cases of patellofemoral instability we must consider bony morphologic features in addition to soft-tissue status.
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103
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Wong TT, Denning J, Moy MP, Rasiej MJ, Redler LH, Ahmad CS, Popkin CA. MRI following medial patellofemoral ligament reconstruction: assessment of imaging features found with post-operative pain, arthritis, and graft failure. Skeletal Radiol 2021; 50:981-991. [PMID: 33083857 DOI: 10.1007/s00256-020-03655-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess MR features following MPFL reconstruction and determine their influence on post-operative pain, progressive arthritis, or graft failure. MATERIALS AND METHODS Retrospective study on 38 patients with MPFL reconstruction and a post-operative MRI between January 2010 and June 2019. Two radiologists assessed MPFL graft signal, graft thickness, femoral screw, femoral tunnel widening, and patellofemoral cartilage damage. The third performed patellofemoral instability measurements. All three assessed femoral tunnel position with final result determined by majority consensus. Imaging findings were evaluated in the setting of post-operative pain, patellofemoral arthritis, and MPFL graft failure including need for MPFL revision. Statistics included chi-square, Fisher's exact test, t test, and kappa. RESULTS Mean graft thickness was 6.0 ± 1.8 mm; 24% of the grafts were diffusely hypointense. Mean femoral tunnel widening was 2.5 ± 1.8 mm; 34% of the femoral screws were broken or extruded. Fifty-two percent of the patients had no interval cartilage change. Non-anatomic femoral tunnels were found in 66% of patients, including in all 9 patients requiring revision MPFL reconstruction (p = 0.013). Revised MPFL grafts had more abnormal femoral screws compared to those that did not (67% vs. 24%) (p = 0.019). Other MR features did not significantly influence the evaluated outcomes. CONCLUSION The need for revision MPFL reconstruction occurs more frequently when there is a non-anatomic femoral tunnel and broken or extruded femoral screws. The appearance of the MPFL graft itself is not an influencing factor for post-operative pain, progression of patellofemoral arthritis, or graft failure.
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Affiliation(s)
- Tony T Wong
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA.
| | - John Denning
- New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, New York, NY, 10032, USA
| | - Matthew P Moy
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Michael J Rasiej
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Lauren H Redler
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Charles A Popkin
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
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104
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Zhao Z, Wang Y, Li J, Wang H, Bai X, Wang Q, Li Z. Clinical Outcomes and Prognostic Factors in Patients With Recurrent Patellar Lateral Dislocation Treated With Isolated Medial Patellofemoral Ligament Reconstruction: A Retrospective Single-Center Analysis. Orthop J Sports Med 2021; 9:2325967121995803. [PMID: 33954219 PMCID: PMC8044575 DOI: 10.1177/2325967121995803] [Citation(s) in RCA: 7] [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] [Received: 10/27/2020] [Accepted: 11/29/2020] [Indexed: 12/19/2022] Open
Abstract
Background Medial patellofemoral ligament reconstruction (MPFLR) is widely used to treat patellofemoral instability. However, it is still unclear when a concomitant bony procedure is needed. Purpose To evaluate the therapeutic efficacy of isolated MPFLR for recurrent patellar lateral dislocation and to identify the prognostic factors for clinical outcomes. Study Design Case series; Level of evidence, 4. Methods A total of 237 patients who had undergone unilateral isolated MPFLR between January 2011 and December 2016 were included. Patellar tracking (J sign) and radiologic information including patellar height, trochlear dysplasia, tibial tubercle-trochlear groove distance, and patellar tilt was collected preoperatively, and the Kujala and International Knee Documentation Committee (IKDC) functional scores were used to assess postoperative recovery. Failure was defined as redislocation or patient-reported and clinically confirmed patellar instability. The influence of radiologic features and the J sign on knee functional scores was explored via subgroup analysis. Potential prognostic factors were explored using univariate and multivariate regression analyses, and risk factors for a positive J sign were evaluated using Spearman coefficient correlation analysis. Results The mean ± SD follow-up period was 70.67 ± 18.05 months (range, 36-108 months). From preoperatively to final follow-up, all patients had statistically and clinically significant improvements in the Kujala score (from 51.43 ± 6.87 to 88.52 ± 4.83; P < .001) and IKDC score (from 49.78 ± 6.05 to 81.16 ± 4.20; P < .001). Subgroup analysis indicated no significant difference in functional score improvements based on radiologic features or the J sign. Overall, 20 knees (8.4%) experienced postoperative failure: 11 with redislocation and 9 with patellar instability. A preoperative positive J sign was shown to be an independent prognostic factor for postoperative failure via logistic regression analyses: univariate (odds ratio, 3.340; 95% CI, 1.316-8.480; P = .011) and multivariate (odds ratio, 3.038; 95% CI, 1.179-7.827; P = .021). In addition, the J sign was closely associated with patellar height (r S, 0.159; P = .014) and trochlear dysplasia (r S, 0.235; P < .001). Conclusion Isolated MPFLR appears to be an effective strategy for recurrent patellar lateral dislocation, with significant functional improvement and a low failure rate. A preoperative positive J sign was identified as a potential prognostic risk factor for postoperative failure.
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Affiliation(s)
- Zhidong Zhao
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuxing Wang
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ji Li
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Haoran Wang
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaowei Bai
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qi Wang
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhongli Li
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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105
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Zhang Z, Song G, Zheng T, Ni Q, Feng H, Zhang H. The presence of a preoperative high-grade J-sign and femoral tunnel malposition are associated with residual graft laxity after MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1183-1190. [PMID: 32627045 DOI: 10.1007/s00167-020-06140-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/30/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to analyse the risk factors associated with residual graft laxity after medial patellofemoral ligament reconstruction (MPFL-R) in patients with recurrent patellar dislocation (RPD). METHODS A total of 312 consecutive patients (354 knees) with clinically diagnosed RPD who underwent MPFL-R from 2011 to 2015 were retrospectively analysed. Postoperative MPFL graft stability was assessed with patellofemoral stress radiography, and if the patellar central ridge surpassed the apex of the lateral femoral trochlea, the reconstructed MPFL was defined as having residual graft laxity. Finally, 15 patients who exhibited MPFL residual graft laxity (study group) were matched in a 1:2 fashion to 30 control participants (control group), who showed a normal postoperative patellar stability on stress radiography. Preoperative three-dimensional computed tomography (3D-CT) was used to identify patients with a high-grade J-sign. Femoral tunnel position was assessed using 3D-CT to identify cases with femoral tunnel malposition. Potential predictors of MPFL residual graft laxity, including age, sex, a preoperative high-grade J-sign, femoral tunnel malposition, and several radiological parameters, were assessed by logistic regression analysis. RESULTS A preoperative high-grade J-sign was identified in 66.7% of the study group, which was significantly higher than that the 13.3% in the control group (P = 0.001). In addition, the presence of a preoperative high-grade J-sign (odds ratio, 11.9 [95% CI, 1.7-82.8]; P = 0.012) and femoral tunnel malposition (odds ratio, 8.2 [95% CI, 1.2-58.0]; P = 0.036) were determined to be independent risk factors associated with residual graft laxity after MPFL-R. CONCLUSION The presence of a preoperative high-grade J-sign and femoral tunnel malposition are associated with residual graft laxity after MPFL-R in patients with RPD. These results may provide additional information for counselling patients on residual graft laxity after MPFL-R. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - GuanYang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - QianKun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China.
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China.
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106
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Manjunath AK, Hurley ET, Jazrawi LM, Strauss EJ. Return to Play After Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Am J Sports Med 2021; 49:1094-1100. [PMID: 32866030 DOI: 10.1177/0363546520947044] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is being performed more frequently in athletes experiencing recurrent patellar instability. PURPOSE/HYPOTHESIS The purpose was to systematically review the evidence in the orthopaedic sports medicine literature to determine both the rate and timing of return to play after MPFL reconstruction and the rate of further patellar instability. Our hypothesis was that there would be a high rate of return to play after MPFL reconstruction. STUDY DESIGN Systematic review. METHODS A systematic literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which utilized EMBASE, MEDLINE, and the Cochrane Library databases. Inclusion criteria for literature included clinical studies reporting on return to play after MPFL reconstruction. Rate of return to play, level of return, timing of return, rate of recurrent instability, and patient-reported outcomes were evaluated. Statistical analysis was performed using SPSS. RESULTS Our review found 27 studies including 1278 patients meeting our inclusion criteria. The majority of patients were women (58%), and the total group had a mean age of 22.0 years and a mean follow-up of 39.3 months. The overall rate of return to play was 85.1%, with 68.3% returning to the same level of play. The average time to return to play was 7.0 months postoperatively. The rate of recurrent instability events following reconstruction was 5.4%. There was an improvement in both mean visual analog scale, pain scores (preoperative: 4.3, postoperative: 1.6) and Tegner activity scores (preoperative: 4.8, postoperative: 5.5). CONCLUSION The overall rate of return to play was high after MPFL reconstruction for the treatment of recurrent patellar instability. However, a relatively high percentage of those patients were unable to return to their preoperative level of sport. Additionally, there was a moderate time taken to return to play, at approximately 7 months after the procedure.
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Affiliation(s)
- Amit K Manjunath
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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107
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Hiemstra LA, Kerslake S, Lafave MR, Tucker A. Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2021; 29:546-552. [PMID: 32274546 DOI: 10.1007/s00167-020-05977-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 03/30/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. METHODS Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. RESULTS Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship. CONCLUSION This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.
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Affiliation(s)
- Laurie Anne Hiemstra
- Banff Sport Medicine, PO Box 1300, Banff, AB, T1L 1B3, Canada. .,Department of Surgery, University of Calgary, Calgary, Canada.
| | - Sarah Kerslake
- Banff Sport Medicine, PO Box 1300, Banff, AB, T1L 1B3, Canada
| | - Mark R Lafave
- Department of Health and Physical Education, Mount Royal University, Calgary, Canada
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108
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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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109
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Leite CBG, Santos TP, Giglio PN, Pécora JR, Camanho GL, Gobbi RG. Tibial Tubercle Osteotomy With Distalization Is a Safe and Effective Procedure for Patients With Patella Alta and Patellar Instability. Orthop J Sports Med 2021; 9:2325967120975101. [PMID: 33553451 PMCID: PMC7829522 DOI: 10.1177/2325967120975101] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Tibial tubercle osteotomy with concomitant distalization for the treatment of
patellar instability remains controversial, as it may cause anterior knee
pain and chondral degeneration. Purpose: To evaluate radiographic, clinical, and functional outcomes in patients who
had patellar instability with patella alta and underwent tibial tubercle
osteotomy with distalization (TTO-d) as well as medial patellofemoral
ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 25 patients (31 cases) (mean age at surgery, 28.7
years; range, 14-33 years) with patellar instability and patella alta who
underwent TTO-d with minimum 1-year follow-up. The Caton-Deschamps index
(CDI), tibial tubercle–trochlear groove (TT-TG) distance, and amount of
distalization were assessed. Clinical and functional variables included
J-sign, anterior knee pain, apprehension test, Tegner activity level, and
Kujala score. Results: The mean follow-up period was 2.62 years. The mean TT-TG was 16.15 mm (range,
7-24 mm); the mean CDI changed from 1.37 (1.25-1.7) preoperatively to 1.02
(0.9-1.12) postoperatively (P = .001); and the mean amount
of tibial tubercle distalization was 8.80 mm (range, 4-16 mm). Lateral
release (22 cases; 71.0%), medialization of tibial tubercle (17 cases;
54.8%), and autologous chondrocyte implantation (4 cases; 12.9%) were other
associated procedures. The J-sign improved in 30 cases (96.8%;
P = .001), and there was a complete resolution of
anterior knee pain in 22 cases (71.0%; P = .001). An
exploratory analysis showed that patellar cartilage defect severity was
correlated with persistent pain (P = .005). The
apprehension test became negative in all cases (P = .001).
The median Kujala score increased from 52 to 77 (P = .001),
and the median Tegner activity level improved from 3 to 4
(P = .001). No cases of osteotomy nonunion were
reported. One case (3.2%) of patellar instability recurrence and 3 cases
(6.5%) with painful hardware were observed. Conclusion: TTO-d resulted in good radiographic, clinical, and functional outcomes
providing proper patellar stability to patients with patella alta. TTO-d
appears to be a safe and efficient procedure with low complication rates,
providing an additional tool for the personalized treatment of patellar
instability.
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Affiliation(s)
- Chilan B G Leite
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Társis P Santos
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Pedro N Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José R Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto L Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo G Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Complex patellofemoral reconstruction leads to improved physical and sexual activity in female patients suffering from chronic patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2021; 29:3017-3024. [PMID: 33119832 PMCID: PMC8384801 DOI: 10.1007/s00167-020-06340-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To analyze postoperative physical and sexual activity as well as Quality of Life (QoL) after complex patellofemoral reconstructions in female patients suffering from chronic patellofemoral instability (PFI). METHODS Female patients aged > 18 years undergoing complex patellofemoral reconstruction for chronic PFI were included. Complex patellofemoral reconstruction was defined as medial patellofemoral ligament reconstruction (MPFL-R) combined with at least one major bony procedure (distal femoral osteotomy, high tibial osteotomy, and trochleoplasty). Outcome was evaluated retrospectively after a minimum follow-up of 12 months using Tegner activity scale, Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0), EuroQol-5D-3L (EQ-5D-3L), EuroQol Visual analog scale (EQ-VAS), and a questionnaire about sexual activity. RESULTS A total of 34 females (mean age, 26 ± 5 years) with a mean follow-up of 45 ± 16 months were included. Seventy-seven percent had one major bony correction + MPFL-R and 24% had at least two major bony corrections + MPFL-R. The re-dislocation rate was 6%. Median Tegner activity scale improved from 3 (range 0-10) to 4 (range 2-6) (n.s.) and an improved activity level was observed in 49% of subjects. QoL scores showed an EQ-5D-3L Index Value of 0.89 ± 0.15, EQ-VAS of 80.3 ± 11.4, and BPII of 68.3 ± 19.1. Thirty-four percent of patients reported restrictions of sexual activities due to PFI preoperatively with an improved sexual function observed in 60% postoperatively due to less pain, improved mobility, and less apprehension. Postoperative return to sexual activity was 91%, whereof 19% reported current restrictions of sexual function because of pain and/or limited range of motion. CONCLUSION Despite the complexity and invasiveness of complex patellofemoral reconstruction, combined bony procedures and MPFL-R resulted in a low redislocation rate, improved physical activity and QoL comparable to values reported after isolated MPFL-R. Furthermore, sexual activity was improved in 60% of females with preoperative restrictions. LEVEL OF EVIDENCE IV.
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111
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Zhang Z, Song G, Li Y, Zheng T, Ni Q, Feng H, Zhang H. Medial Patellofemoral Ligament Reconstruction With or Without Derotational Distal Femoral Osteotomy in Treating Recurrent Patellar Dislocation With Increased Femoral Anteversion: A Retrospective Comparative Study. Am J Sports Med 2021; 49:200-206. [PMID: 33180556 DOI: 10.1177/0363546520968566] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy exists regarding the surgical treatment of recurrent patellar dislocation (RPD) with an increased femoral anteversion angle (FAA). Medial patellofemoral ligament reconstruction (MPFL-R) either alone or combined with derotational distal femoral osteotomy (DDFO) results in favorable clinical outcomes. PURPOSE To compare the clinical outcomes of MPFL-R versus MPFL-R with DDFO in treating RPD with increased FAA (>30°). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between January 2014 and December 2017, 126 patients (135 knees) with RPD and increased FAA (>30°) were surgically treated using MPFL-R with or without DDFO and eligible for this retrospective study. These patients were allocated into 2 groups based on whether an additional DDFO was performed: the DDFO group (MPFL-R + DDFO with or without tibial tubercle transfer; n = 66) and the control group (MPFL-R with or without tibial tubercle transfer; n = 69). Pre- and postoperative patellar stability was measured using stress radiography. Patellar maltracking (J-sign) and patient-reported outcomes (Kujala, International Knee Documentation Committee, Lysholm, and Tegner scores) were evaluated and compared between the 2 groups. Subgroup analysis was performed by stratifying the results in terms of the severity of preoperative patellar maltracking (low-grade vs high-grade J-sign). RESULTS A total of 135 knees (126 patients) with a mean follow-up time of 3.7 ± 1.2 years were evaluated in the present study. The rates of postoperative MPFL residual graft laxity and residual J-sign were significantly lower in the DDFO group than in the control group (6% vs 19%, P = .028; 33% vs 54%, P = .018). The DDFO group had significantly higher Kujala (82.3 vs 76.7; P = .001) and Lysholm (83.7 vs 77.7; P = .034) scores than the control group had postoperatively. For patients with a preoperative high-grade J-sign, further subgroup analysis demonstrated that the DDFO group had a significantly lower rate of MPFL residual graft laxity than the control group had (18% vs 57%; P = .029). CONCLUSION In this retrospective study, treatment of RPD with increased femoral anteversion using MPFL-R with DDFO yielded more favorable subjective and objective outcomes than did MPFL-R without DDFO, and this circumstance was more remarkable when the patients had a preoperative high-grade J-sign.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Guanyang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Yue Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - QianKun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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Zimmermann F, Börtlein J, Milinkovic DD, Balcarek P. Patient-Reported Outcomes After Revision Surgery for Failed Medial Patellofemoral Ligament Reconstruction: A Matched-Pair Analysis Including Correction of Predisposing Factors. Am J Sports Med 2020; 48:3566-3572. [PMID: 33104394 DOI: 10.1177/0363546520966354] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complications and the need for revision surgery after medial patellofemoral ligament reconstruction (MPFLR) are evident in the current literature. However, there is a shortage of clinical data evaluating the results of revision surgery in individual patients after failed MPFLR. PURPOSE To investigate the results of tailored revision surgery for failed MPFLR, including the correction of predisposing factors. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between August 2015 and March 2019, 25 patients (male:female, n = 9:16; mean ± SD age, 25.9 ± 6.5 years) underwent revision surgery for failed MPFLR (study group). The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analog scale (0-10) for patellofemoral pain and subjective knee joint function were used to assess patient-reported quality of life before and after revision surgery. The control group of 50 patients (male:female, n = 18:32; age, 22.8 ± 4.3 years) who underwent identical patellar-stabilizing procedures was matched 1:2 by the surgical procedure, predisposing factors, sex, age, and follow-up time. RESULTS Evaluation was performed postoperatively at a mean 27.8 ± 14.0 months (range, 12-54 months) in the study group and 26.1 ± 11.2 months (range, 12-56 months) in the control group (P = .55). The BPII 2.0 score increased from 28.6 ± 17.9 points to 68.7 ± 22.3 points (P < .0001) in the study group and from 43.8 ± 22.5 points to 75.5 ± 21.4 points (P < .0001) in the control group from preoperatively to postoperatively, respectively. Before revision surgery, the BPII 2.0 scores in the study group were significantly inferior to those in the control group (P = .0026). At the final follow-up, the BPII 2.0 score in the study group was not significantly lower (P = .174), and a similar number of patients in the study group and the control group achieved the minimally clinically important difference (P = .49). Patellofemoral pain and subjective knee joint function improved significantly in both groups (P < .0001, P < .0001), without any significant difference between them at the final follow-up (P = .85, P = .86). CONCLUSION Revision surgery for MPFLR failure, including the correction of major anatomic risk factors, yielded a significant improvement in patient-reported quality-of-life outcome measures. Patients with failed MPFLR, however, were significantly more restricted before revision surgery than patients without previous interventions when evaluated with the BPII 2.0.
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Affiliation(s)
- Felix Zimmermann
- Arcus Sportklinik, Pforzheim, Germany.,BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany
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Davies MR, Allahabadi S, Diab TE, Freshman RD, Pandya NK, Feeley BT, Lansdown DA. Sulcus-Deepening Trochleoplasty as an Isolated or Combined Treatment Strategy for Patellar Instability and Trochlear Dysplasia: A Systematic Review. Arthrosc Sports Med Rehabil 2020; 2:e661-e669. [PMID: 33135008 PMCID: PMC7588636 DOI: 10.1016/j.asmr.2020.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/21/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To highlight the indications and outcomes for sulcus-deepening trochleoplasty, when used as an isolated procedure as well as in combination with other stabilization techniques for patellar instability. Methods We performed a systematic review focused on outcomes and complications following trochleoplasty performed either as an isolated procedure or in combination with other procedures to address patellar instability. Inclusion criteria included studies in English that reported on outcomes following primary open trochleoplasty, including Kujala scores and recurrent instability or dislocation events. Results Twelve papers including 702 patients who underwent sulcus-deepening trochleoplasty were included. A total of 504 patients underwent isolated sulcus-deepening trochleoplasty, whereas 198 patients underwent trochleoplasty in combination with 1 or more additional stabilization procedures. In total, 67% of patients were female compared with 33% male. The procedure was done was a primary surgical intervention 74% of the time. Postoperative Kujala scores for isolated trochleoplasty ranged from 80 to 92, whereas those for combined stabilization procedures ranged from 76 to 95. The dislocation rate among the studies ranged from 0 to 8%. There was a persistent J-sign in 0 to 12% of treated knees among all studies, and a persistent apprehension test in 0 to 29% of treated knees. Return to play ranged from 65% to 83% in studies in which this was reported as an outcome. Conclusions Sulcus-deepening trochleoplasty performed for recurrent patellar instability in the setting of trochlear dysplasia results in improved Kujala scores and a low redislocation rate, when performed as an isolated procedure or in combination with other stabilization procedures. Greater-level evidence is needed to better evaluate the overall efficacy of this procedure in addressing patellar instability. Level of Evidence Level of Evidence, IV; Systematic review of level III and IV studies.
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Affiliation(s)
- Michael Robert Davies
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Tarek Elliott Diab
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Ryan David Freshman
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Nirav Kiritkumar Pandya
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Brian Thomas Feeley
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Drew Anderson Lansdown
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
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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] [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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Instabile Patella des Erwachsenen. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00405-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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116
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Zhang Z, Song G, Ni Q, Zheng T, Cao Y, Feng Z, Zhang H, Feng H. Preoperative Complete Patellofemoral Dislocation in Extension Predicts an Inferior Clinical Outcome After Medial Patellofemoral Ligament Reconstruction in Patients With Recurrent Patellar Dislocation. Orthop J Sports Med 2020; 8:2325967120938981. [PMID: 32864383 PMCID: PMC7430086 DOI: 10.1177/2325967120938981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Habitual patellar dislocation in extension (HPD-E) is a distinctive subtype
of recurrent patellar dislocation (RPD); HPD-E represents the most severe
type of patellar maltracking in RPD. It has been reported that the presence
of preoperative patellar maltracking is associated with a worse clinical
outcome after medial patellofemoral ligament (MPFL) reconstruction
(MPFL-R). Purpose: To describe the radiological characteristics of HPD-E and to compare clinical
outcomes after MPFL-R among patients with and without preoperative
HPD-E. Study Design: Cohort study; Level of evidence, 3. Methods: From January 2012 to December 2015, a total of 230 consecutive patients (246
knees) with RPD were treated with MPFL-R alone or combined with tibial
tubercle osteotomy. Among them, 28 patients diagnosed with HPD-E by
preoperative 3-dimensional computed tomography (CT; HPD-E group) were
matched in a 1:1 fashion to 28 control participants who did not show HPD-E
(control group). Routine radiography and CT were performed to evaluate
patellar height, trochlear dysplasia, tibial tubercle–trochlear groove
distance, and torsional deformities. The mean patellar laxity index and
lateral patellar translation assessed with stress radiography were measured
preoperatively and postoperatively to quantify MPFL laxity. At minimum
2-year follow-up, patient-reported outcomes (Kujala, Lysholm, and Tegner
scores), patellar maltracking, and redislocation rates were compared between
the HPD-E and control groups. Results: The radiological characteristics of the HPD-E group were as follows: 89%
(25/28) of patients had severe trochlear dysplasia (Dejour type B or D), and
the mean femoral anteversion angle was 35.5° ± 4.7°. At the final follow-up,
the HPD-E group had a significantly lower Kujala score (76.2 vs 84.5,
respectively; P = .001), Lysholm score (75.4 vs 86.6,
respectively; P < .001), and Tegner score (4.1 vs 5.8,
respectively; P = .021) compared with the control group.
The postoperative patellar laxity index (43% vs 19%, respectively;
P < .001) and redislocation rate (25% vs 0%,
respectively; P = .01) were significantly higher in the
HPD-E group than in the control group. Conclusion: Preoperative 3-dimensional CT is a reliable method of identfying patients
with HPD-E. Treatment of HPD-E by MPFL-R alone or combined with tibial
tubercle osteotomy resulted in a higher redislocation rate, more severe MPFL
residual laxity, and lower patient-reported outcome scores compared with
patients without HPD-E who underwent MPFL-R.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - GuanYang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - QianKun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Yanwei Cao
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Zheng Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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Zhang Z, Zhang H, Song G, Zheng T, Ni Q, Feng H. Increased femoral anteversion is associated with inferior clinical outcomes after MPFL reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:2261-2269. [PMID: 31797022 DOI: 10.1007/s00167-019-05818-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 11/27/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE This study aimed at investigating the influence of an increased femoral anteversion angle on clinical outcomes after medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. It was hypothesized that an increased femoral anteversion is associated with inferior clinical outcomes. METHODS From 2014 to 2016, a total of 144 consecutive patients with recurrent patellar instability were treated with medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy. The femoral anteversion angle was measured using three-dimensional computed tomography scans. Patients were allocated into group A (femoral anteversion < 20°), group B (femoral anteversion 20°-30°) and group C (femoral anteversion > 30°) based on the value of the femoral anteversion angle. Routine radiography and CT examinations were performed to evaluate the patellar height, trochlear dysplasia, genu valgum, and tibial tuberosity-trochlear groove (TT-TG) distance. The patellar lateral shift distance assessed with stress radiography was used pre- and postoperatively to quantify medial patellofemoral ligament residual laxity under anaesthesia. Patient-reported outcomes (Kujala, IKDC, and Lysholm scores) and patellar maltracking ("J-sign") were evaluated pre- and postoperatively. Finally, subgroup analysis was performed to investigate the influence of an increased femoral anteversion angle on the clinical and radiological outcomes. RESULTS A total of 66 patients (70 knees) were included with a median follow-up time of 28 months (range 24-32). After a minimum of 2 years of follow-up, all patient-reported outcomes (Kujala, Lysholm, and IKDC scores) improved significantly, and subgroup analysis showed that group C had significantly lower Kujala scores (75 ± 8 vs. 84 ± 8, P13 = 0.003; 75 ± 8 vs. 82 ± 8, P23 = 0.030), Lysholm scores (81 ± 9 vs. 87 ± 7, P13 = 0.021) and IKDC scores (78 ± 6 vs. 85 ± 7, P13 = 0.001; 78 ± 6 vs. 84 ± 6, P23 = 0.005) than group A and group B. Twelve patients had a postoperative residual J-sign (17.1%), and significant differences were found between group C and group A regarding the rate of residual J-sign (32.1% vs. 4.8%, P13 = 0.003). Postoperatively, group C had a greater patellar lateral shift distance than group A (10 ± 4 vs. 6 ± 4 mm, P13 = 0.006) and group B (10 ± 4 vs. 6 ± 3 mm, P23 = 0.008). Additionally, patients with a residual J-sign demonstrated greater medial patellofemoral ligament laxity than patients without a residual J-sign (12 ± 4 vs. 9 ± 3 mm, P = 0.009). CONCLUSION Patients with an increased femoral anteversion angle (> 30°) had inferior postoperative clinical outcomes, including greater patellar laxity, a higher rate of residual J-sign and lower patient-reported outcomes after medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - GuanYang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - QianKun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China.
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Zhang Z, Zhang H, Song G, Zheng T, Feng H. A pre-operative grade 3 J-sign adversely affects short-term clinical outcome and is more likely to yield MPFL residual graft laxity in recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2020; 28:2147-2156. [PMID: 31612265 DOI: 10.1007/s00167-019-05736-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The purposes of this study were to investigate the anatomical risk factors of grade 3 J-sign and analyse the influence of J-sign grades on the short-term clinical outcomes of patients with recurrent patellar dislocation. METHODS From 2016 to 2018, a total of 168 patients with recurrent patellar dislocation (187 knees) underwent medial patellofemoral ligament reconstruction with or without tibial tuberosity medialization. Pre-operative J-sign severity was graded according to a previously described classification (grades 1-3). Potential anatomical risk factors of J-sign were explored. Comparisons were assessed between patients with different grades of J-sign using univariate and binary logistic regression analyses. The Kujala score was assessed and compared with pre-operative values, and stress fluoroscopy was performed to assess medial patellofemoral ligament residual graft laxity. Among the 130 included cases, 104 knees with at least 1-year follow-up were included in the clinical outcome analyses to explore the influence of several anatomical factors and J-sign grade on short-term clinical outcomes. RESULTS A total of 118 patients (130 knees) were included in the present study. The median age at surgery was 21 years (range 13-38), and 111 affected knees belonged to female patients (85%). Univariate and multivariate logistic regressions between the grade 3 group and the grade 1-2 groups showed that increased femoral anteversion, excessive external tibial torsion, and patella alta were three independent risk factors of grade 3 J-sign in patients with recurrent patellar dislocation. A total of 104 knees with at least a 1-year follow-up were included in the clinical outcome analyses. The median Kujala score improved from 54 (range, 38-72) pre-operatively to 86 (range, 70-100) post-operatively. Although no re-dislocation was reported during the follow-up, 6 out of 32 patients in the grade 3 group demonstrated "MPFL residual graft laxity" based on post-operative stress radiography (18.8%), which was significantly higher than in the grade 1-2 groups (0%, p < 0.001). Subgroup analysis showed that patients with grade 3 J-sign had significantly lower post-operative Kujala scores than those with grade 1-2 J-sign (p < 0.001). Moreover, increased femoral anteversion (≥ 30°) was correlated with an inferior post-operative Kujala score (p = 0.023). CONCLUSION The three independent anatomic risk factors of grade 3 J-sign in patients with recurrent patellar dislocation were increased femoral anteversion, excessive external tibial torsion, and patella alta. A pre-operative grade 3 J-sign was correlated with a lower post-operative Kujala score and more "MPFL residual graft laxity" in patients with recurrent patellar dislocation treated with MPFL reconstruction with or without tibial tuberosity medialization at a minimum 1-year follow-up. LEVEL OF EVIDENCE III.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - GuanYang Song
- Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China.
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Feucht MJ, Mehl J, Forkel P, Achtnich A, Schmitt A, Izadpanah K, Imhoff AB, Berthold DP. Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120926178. [PMID: 32613021 PMCID: PMC7309400 DOI: 10.1177/2325967120926178] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index <0.28), lateralization of the tibial tuberosity (tibial tuberosity–trochlear groove distance >20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.
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Affiliation(s)
- Matthias J Feucht
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Julian Mehl
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Philipp Forkel
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andrea Achtnich
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andreas Schmitt
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel P Berthold
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
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Puzzitiello RN, Agarwalla A, Waterman BR, Verma N, Cole BJ, Yanke A, Forsythe B. Author Reply to "Regarding "Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population". Arthroscopy 2020; 36:1496-1499. [PMID: 32503766 DOI: 10.1016/j.arthro.2020.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam Yanke
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian Forsythe
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
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Eliasberg CD, Diduch DR, Strickland SM. Failure of Patellofemoral Joint Preservation. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2019.150715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zhang Z, Zhang H, Song G, Wang X, Zhang J, Zheng T, Ni Q, Feng H. A High-Grade J Sign Is More Likely to Yield Higher Postoperative Patellar Laxity and Residual Maltracking in Patients With Recurrent Patellar Dislocation Treated With Derotational Distal Femoral Osteotomy. Am J Sports Med 2020; 48:117-127. [PMID: 31765235 DOI: 10.1177/0363546519884669] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It has been speculated that the patellar J sign may have a negative effect on the clinical outcomes of patients with recurrent patellar dislocation (RPD). PURPOSE To (1) evaluate clinical outcomes, postoperative patellar stability, and patellar maltracking correction in patients with RPD treated with derotational distal femoral osteotomy (DDFO) and combined procedures and (2) investigate the influence of J sign severity on the clinical outcomes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between January 2015 and December 2016, a total of 78 patients (81 knees) with RPD, a positive J sign, and an excessive femoral anteversion angle (FAA; ≥30°) were surgically treated with DDFO and combined procedures. J sign severity was graded according to a previously described classification system (grades 1-3). Routine radiography and computed tomography were performed on every patient to evaluate the patellar height, trochlear dysplasia, genu valgum, tibial tuberosity-trochlear groove distance, patellar lateral tilt angle, and patella-trochlear groove distance. The patellar lateral shift distance during stress radiography was measured preoperatively and postoperatively to quantify medial patellofemoral ligament (MPFL) graft laxity under anesthesia, and "MPFL residual graft laxity" was defined as the patellar ridge surpassing the apex of the lateral femoral trochlea. Patients were evaluated using the Kujala, International Knee Documentation Committee (IKDC), and Lysholm scores preoperatively and postoperatively. Patients were allocated into 3 subgroups in terms of the severity of the J sign: low-grade group 1 (grade 1; n = 19), low-grade group 2 (grade 2; n = 16), and high-grade group (grade 3; n = 12). Subgroup analyses were performed to investigate the influence of a high-grade J sign on the clinical outcomes. RESULTS Among the 78 patients (81 knees), 47 patients (47 knees) met the inclusion criteria. The mean follow-up time was 26.1 ± 1.7 months. The mean preoperative and postoperative FAAs were 36.2°± 5.3° and 10.0°± 2.1°, respectively, with a mean correction angle of 26.2°± 5.9°. At the final follow-up, all patient-reported outcomes improved significantly, and subgroup analyses showed that the high-grade group had significantly lower Kujala scores (75.6 vs 85.3 for low-grade group 1 [P < .001] and 83.4 for low-grade group 2 [P = .001]), Lysholm scores (77.6 vs 84.6 for low-grade group 1 [P = .003]), and IKDC scores (78.6 vs 87.3 for low-grade group 1 [P = .001] and 84.3 for low-grade group 2 [P = .033]) than the low-grade groups. The total rate of MPFL residual graft laxity was 8.5% (4/47), and the prevalence of the postoperative residual J sign was 38.3% (18/47). Subgroup analyses showed significant differences between the high-grade group and the 2 low-grade groups with regard to the MPFL residual graft laxity rate (33.3% vs 0.0% for low-grade group 1 [P = .016] and 0.0% for low-grade group 2 [P = .024]), residual J sign rate (91.7% vs 15.8% for low-grade group 1 [P < .001] and 25.0% for low-grade group 2 [P < .001]), and patellar lateral shift distance (14.2 vs 8.1 mm for low-grade group 1 [P = .002] and 8.7 mm for low-grade group 2 [P = .007]). CONCLUSION In a group of patients treated for RPD with a positive preoperative J sign and increased FAA (≥30°), patients with a preoperative high-grade J sign had inferior clinical outcomes, more MPFL residual graft laxity, and greater residual patellar maltracking.
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Affiliation(s)
- ZhiJun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - GuanYang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - XueSong Wang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Jin Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - QianKun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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Lösungen für häufige Komplikationen bei Patella-Stabilisierungseingriffen. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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