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Stokes DJ, Elrick BP, Carpenter ML, Raji Y, McQuivey KS, Sherman SL, Frank RM. Tibial Tubercle Osteotomy: Indications, Outcomes, and Complications. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09915-w. [PMID: 39102076 DOI: 10.1007/s12178-024-09915-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE OF REVIEW The tibial tubercle osteotomy (TTO) is a versatile surgical technique used to treat a range of patellofemoral disorders, including patellar instability, painful malalignment, focal chondral defects, and patellar maltracking that have failed conservative therapies. TTO is a personalized procedure that can be tailored to the pathoanatomy of the patient based on physical examination and imaging. The complication rate associated with TTO strongly depends on the indication for surgery, the severity of the patient's condition, and the surgical approach. Despite the literature on TTO, to our knowledge, no single source has addressed the indications, techniques, outcomes, and complications of this procedure. The purpose of this article is to serve as such a valuable resource. RECENT FINDINGS Highlights from recent studies we would like to emphasize are two-fold. First, maintaining a distal cortical hinge yields lower complication rates than osteotomies involving complete tubercle detachment with classic or standard techniques. Second, based on current evidence, TTO consistently provides symptomatic relief, and most patients can return to work or sport at their pre-operative level within 3 and 6 months, respectively. TTO is a personalizable surgical technique that may be utilized for multiple patellofemoral disorders and is associated with good outcomes.
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Affiliation(s)
- Daniel J Stokes
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryant P Elrick
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Melissa L Carpenter
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Yazdan Raji
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Kade S McQuivey
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- UCHealth CU Sports Medicine - CO Center, 2000 S. Colorado Blvd Tower 1, Suite 4500, Denver, CO, 80222, USA.
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Arias C, Lustig S. Physiopathology of patello-femoral osteoarthritis: current concepts. J ISAKOS 2024; 9:806-813. [PMID: 38897413 DOI: 10.1016/j.jisako.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/21/2024]
Abstract
Patellofemoral osteoarthritis (PFOA) is the result of degeneration and loss of articular cartilage of the patella and trochlea, and is a common cause of anterior knee pain. PFOA is triggered by insufficient adaptation to overload of the articular cartilage of the PF joint created by abnormal biomechanics. It is important to understand the pathophysiology and natural history to make the diagnosis and to plan treatment. Innate factors including malalignment, patellar instability, kinematic disorders, and acquired factors like trauma, obesity, and endocrine diseases have been found to be causes of PFOA. Genetic predisposition is also described as a contributing cause but without much scientific evidence. The diagnosis will be based on clinical manifestations, such as anterior knee pain aggravated by overloading activities, identification of risk factors, and exclusion of referred pain from other pathologies, followed by a systematic and structured physical examination. Imaging will be useful for assessing the presence of early osteoarthritis in the other compartments, for classification of the PFOA, and to identify features to establish an adequate treatment. This paper discusses varying management options for different causes of patellofemoral disease and explains the complexity of the PF joint and its often poorly understood biomechanics.
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Affiliation(s)
| | - Sebastien Lustig
- Orthopedic Surgery Department, Croix-Rousse Hospital, 103 Grande rue de la Croix-Rousse, 69004 Lyon, France
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Ipsilateral patellofemoral morphological abnormalities are more severe than those of contralateral joints in patients with unilateral patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2021; 29:2709-2716. [PMID: 33834257 DOI: 10.1007/s00167-021-06539-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine the differences in anatomic parameters between ipsilateral dislocated knees and contralateral non-dislocated knees in patients with unilateral patellar dislocation and to identify any variations in ipsilateral knees contributing to contralateral anatomic abnormalities. METHODS A total of 82 patients with unilateral patellar dislocation from 2016 to 2019 were retrospectively evaluated. Bilateral anatomic factors, including the tibial tubercle to trochlear groove (TT-TG) distance, lower limb rotational deformities, trochlear dysplasia, patella tilt, and patellar height, were assessed by CT. RESULTS The study included 46 patients (32 females and 14 males, mean age ± SD 20.5 ± 6.8). The interobserver reliability of each parameter showed excellent agreement. The ipsilateral TT-TG distance (P = 0.004), patella tilt (P = 0.001), and patellar height (P = 0.01) were greater in the ipsilateral knees than in the contralateral knees. The lateral trochlea inclination (LTI) in the contralateral knees was larger than that in the ipsilateral knees (P = 0.022). There was a significant difference in the distribution of trochlear dysplasia of Dejour between the ipsilateral knees (dislocated side) and the contralateral knees (P = 0.036). However, bilateral femoral and/or tibial torsion, and bilateral knee joint rotation did not differ significantly. Binary logistic regression showed that only ipsilateral LTI revealed significant ORs of 8.83 (P = 0.016) and 7.64 (P = 0.018) with regard to contralateral abnormal tibial torsion and LTI, respectively. CONCLUSION In patients with unilateral patellar dislocation, the ipsilateral TT-TG distance, patella tilt, and patellar height values were larger in the ipsilateral knees than in the contralateral knees, and trochlear dysplasia was more severe in the ipsilateral joints. The risks of contralateral pathological tibial torsion and LTI were 8.8- and 7.6-fold higher, respectively, in patients with abnormal ipsilateral LTI. LEVEL OF EVIDENCE Level IV.
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Trivellas M, Arshi A, Beck JJ. Roux-Goldthwait and Medial Patellofemoral Ligament Reconstruction for Patella Realignment in the Skeletally Immature Patient. Arthrosc Tech 2019; 8:e1479-e1483. [PMID: 31890526 PMCID: PMC6928364 DOI: 10.1016/j.eats.2019.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/23/2019] [Indexed: 02/03/2023] Open
Abstract
Surgical management of patellofemoral instability is technically challenging in skeletally immature patients. Special considerations in this population include activity and sports limitations, recurrence rate, risk of long-term injury to patellofemoral cartilage, and potential for physeal disruption with operative intervention. Numerous procedures have been described to address causative pathoanatomy in the patellofemoral joint, as well as its static and dynamic stabilizers. We describe our technique of combined medial patellofemoral ligament and modified Roux-Goldthwait reconstruction to address both proximal and distal malalignment in a skeletally immature patient with open physes.
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Affiliation(s)
- Myra Trivellas
- Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, U.S.A
| | - Armin Arshi
- Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, U.S.A
| | - Jennifer J. Beck
- Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, U.S.A.,Orthopedic Institute for Children, Los Angeles, CA, U.S.A.,Address correspondence to Jennifer J. Beck, M.D., Assistant Clinical Professor, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA Pediatric, Sports Medicine Associate Director, Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, CA 90095, U.S.A.
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Abstract
Patellar instability is defined by clinical and radiologic criteria. The surgical treatment is aimed at restoring the congruence of the patellofemoral articulation and correcting extensor mechanism malalignment, to prevent recurrence of dislocation. The standard soft-tissue procedures are lateral release and vastus medialis advancement and medial patello femoral ligament plasty. Bony procedures are frequently performed in addition to soft-tissue surgery, to realign the extensor mechanism by means of tibial tubercle medialization, or to correct the patellar index in patella alta. In a smaller number of patients, the trochlea may be reshaped, by elevating the lateral trochlear facet or by lowering the floor of the sulcus. The morphologic abnormalities encountered are studied and quantified in the light of preoperative investigations (conventional radiographs and computed tomography), and addressed at surgery using the technique or techniques most appropriate for the management of the individual patient's pattern.
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Zaffagnini S, Grassi A, Zocco G, Rosa MA, Signorelli C, Marcheggiani Muccioli GM. The patellofemoral joint: from dysplasia to dislocation. EFORT Open Rev 2017. [PMID: 28630757 PMCID: PMC5467684 DOI: 10.1302/2058-5241.2.160081] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patellofemoral dysplasia is a major predisposing factor for instability of the patellofemoral joint. However, there is no consensus as to whether patellofemoral dysplasia is genetic in origin, caused by imbalanced forces producing maltracking and remodelling of the trochlea during infancy and growth, or due to other unknown and unexplored factors.The biomechanical effects of patellofemoral dysplasia on patellar stability and on surgical procedures have not been fully investigated. Also, different anatomical and demographic risk factors have been suggested, in an attempt to identify the recurrent dislocators. Therefore, a comprehensive evaluation of all the radiographic, MRI and CT parameters can help the clinician to assess patients with primary and recurrent patellar dislocation and guide management.Patellofemoral dysplasia still represents an extremely challenging condition to manage. Its controversial aetiology and its complex biomechanical behaviour continue to pose more questions than answers to the research community, which reflects the lack of universally accepted guidelines for the correct treatment. However, due to the complexity of this condition, an extremely personalised approach should be reserved for each patient, in considering and addressing the anatomical abnormalities responsible for the symptoms. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160081. Originally published online at www.efortopenreviews.org.
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Affiliation(s)
- Stefano Zaffagnini
- Istituto Ortopedico Rizzoli, Dipartimento Rizzoli Sicilia, Bagheria (PA), Italy.,Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
| | - Alberto Grassi
- Istituto Ortopedico Rizzoli, Dipartimento Rizzoli Sicilia, Bagheria (PA), Italy.,Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
| | - Gianluca Zocco
- Dipartimento di Ortopedia e Traumatologia, Department of Biomedical Sciences and Morphological and Functional Images, Scuola Ortopedia e Traumatologia, Università di Messina, Italy
| | - Michele Attilo Rosa
- Dipartimento di Ortopedia e Traumatologia, Department of Biomedical Sciences and Morphological and Functional Images, Scuola Ortopedia e Traumatologia, Università di Messina, Italy
| | - Cecilia Signorelli
- Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
| | - Giulio Maria Marcheggiani Muccioli
- Istituto Ortopedico Rizzoli, Dipartimento Rizzoli Sicilia, Bagheria (PA), Italy.,Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
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Early osteoarthritis of the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc 2016; 24:1836-44. [PMID: 27120193 DOI: 10.1007/s00167-016-4103-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/22/2016] [Indexed: 02/04/2023]
Abstract
Patellofemoral joint cartilage lesions are associated with a variety of clinical situations including blunt trauma, lateral patella dislocations, or as a secondary development in the setting of abnormal joint loading. There is a need for more clarity on how to best address these lesions. Most specifically, when is it necessary to surgically treat these lesions of the patella and trochlea and which technique to use? This review will focus on the spectrum of patellofemoral disease/injury and their treatment strategies, with special emphasis on cartilage damage and early osteoarthritis. Chapter sections will review the most common scenarios of cartilage damage in the patellofemoral joint, with an attempt to summarize current treatment, their outcomes, remaining challenges and unanswered questions.
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Hall MJ, Mandalia VI. Tibial tubercle osteotomy for patello-femoral joint disorders. Knee Surg Sports Traumatol Arthrosc 2016; 24:855-61. [PMID: 25326765 DOI: 10.1007/s00167-014-3388-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/10/2014] [Indexed: 11/25/2022]
Abstract
Tibial tubercle osteotomy has a long history in the management of patella instability and patello-femoral arthritis. This review aims to provide a comprehensive review of the literature describing the biomechanics of the patello-femoral joint and the rationale behind the use of the tibial tubercle osteotomy in modern day practice. Several different tibial tubercle osteotomies are available and we aim to detail the concepts behind their use and the subsequent clinical results. With continued developments of chondrocyte implantation techniques, the potential to fill defects on the chondral surface of either the patella or trochlea in conjunction with a tibial tubercle osteotomy may well become more commonplace in a group that is commonly young and difficult to manage. Level of evidence III.
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Affiliation(s)
- Matthew J Hall
- Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, Somerset, UK.
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Erickson BJ, Mascarenhas R, Sayegh ET, Saltzman B, Verma NN, Bush-Joseph CA, Cole BJ, Bach BR. Does Operative Treatment of First-Time Patellar Dislocations Lead to Increased Patellofemoral Stability? A Systematic Review of Overlapping Meta-analyses. Arthroscopy 2015; 31:1207-15. [PMID: 25636989 DOI: 10.1016/j.arthro.2014.11.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/16/2014] [Accepted: 11/26/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To conduct a systematic review of meta-analyses comparing nonoperative and operative treatment of patellar dislocations to elucidate the cause of the variation and to determine which meta-analysis provides the current best available evidence. METHODS A systematic review of the literature to identify meta-analyses was performed. Data were extracted for patient outcomes and recurrent dislocations. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analysis provided the highest level of evidence. RESULTS Four meta-analyses met the eligibility criteria: 1 Level I evidence, 2 Level II evidence, and 1 Level III evidence. A total of 1,984 patients were included (997 underwent surgery whereas 987 underwent conservative treatment). Three meta-analyses found a lower subsequent patellar dislocation rate in patients managed operatively compared with nonoperatively, whereas one did not find a difference in recurrent dislocation rates between the operative and nonoperative groups. When the results of all the studies were combined, the overall redislocation rate was 29.4% and the rate of recurrent instability episodes was 32.8%. Patients treated operatively had a 24.0% rate of repeat patellar dislocation and a 32.7% rate of recurrent patellar instability, whereas patients treated nonoperatively had a 34.6% rate of repeat patellar dislocation and a 33.0% rate of recurrent instability. In addition, 1 meta-analysis found a significantly higher rate of patellofemoral osteoarthritis in the operative group. No differences in functional outcomes scores were seen between treatments. Two meta-analyses had low Oxman-Guyatt scores (<4), indicative of major flaws. CONCLUSIONS According to the best available evidence, operative treatment of acute patellar dislocations may result in a lower rate of recurrent dislocations than nonoperative treatment but does not improve functional outcome scores. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and II studies.
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Affiliation(s)
- Brandon J Erickson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Randy Mascarenhas
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Eli T Sayegh
- College of Physicians and Surgeons, Columbia University, New York, New York, U.S.A
| | - Bryan Saltzman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Charles A Bush-Joseph
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bernard R Bach
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Smith TO, Donell S, Song F, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2015:CD008106. [PMID: 25716704 DOI: 10.1002/14651858.cd008106.pub3] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patellar dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. Following reduction of the dislocation, conservative (non-surgical) rehabilitation with physiotherapy may be used. Since recurrence of dislocation is common, some surgeons have advocated surgical intervention rather than non-surgical interventions. This is an update of a Cochrane review first published in 2011. OBJECTIVES To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, ZETOC, Physiotherapy Evidence Database (PEDro) and a variety of other literature databases and trial registries. Corresponding authors were contacted to identify additional studies. The last search was carried out in October 2014. SELECTION CRITERIA We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating lateral patellar dislocation. DATA COLLECTION AND ANALYSIS Two review authors independently examined titles and abstracts of each identified study to assess study eligibility, extract data and assess risk of bias. The primary outcomes we assessed were the frequency of recurrent dislocation, and validated patient-rated knee or physical function scores. We calculated risk ratios (RR) for dichotomous outcomes and mean differences MD) for continuous outcomes. When appropriate, we pooled data. MAIN RESULTS We included five randomised studies and one quasi-randomised study. These recruited a total of 344 people with primary (first-time) patellar dislocation. The mean ages in the individual studies ranged from 19.3 to 25.7 years, with four studies including children, mainly adolescents, as well as adults. Follow-up for the full study populations ranged from two to nine years across the six studies. The quality of the evidence is very low as assessed by GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) criteria, with all studies being at high risk of performance and detection biases, relating to the lack of blinding.There was very low quality but consistent evidence that participants managed surgically had a significantly lower risk of recurrent dislocation following primary patellar dislocation at two to five years follow-up (21/162 versus 32/136; RR 0.53 favouring surgery, 95% confidence interval (CI) 0.33 to 0.87; five studies, 294 participants). Based on an illustrative risk of recurrent dislocation in 222 people per 1000 in the non-surgical group, these data equate to 104 fewer (95% CI 149 fewer to 28 fewer) people per 1000 having recurrent dislocation after surgery. Similarly, there is evidence of a lower risk of recurrent dislocation after surgery at six to nine years (RR 0.67 favouring surgery, 95% CI 0.42 to 1.08; two studies, 165 participants), but a small increase cannot be ruled out. Based on an illustrative risk of recurrent dislocation in 336 people per 1000 in the non-surgical group, these data equate to 110 fewer (95% CI 195 fewer to 27 more) people per 1000 having recurrent dislocation after surgery.The very low quality evidence available from single trials only for four validated patient-rated knee and physical function scores (the Tegner activity scale, KOOS, Lysholm and Hughston VAS (visual analogue scale) score) did not show significant differences between the two treatment groups.The results for the Kujala patellofemoral disorders score (0 to 100: best outcome) differed in direction of effect at two to five years follow-up, which favoured the surgery group (MD 13.93 points higher, 95% CI 5.33 points higher to 22.53 points higher; four studies, 171 participants) and the six to nine years follow-up, which favoured the non-surgical treatment group (MD 3.25 points lower, 95% CI 10.61 points lower to 4.11 points higher; two studies, 167 participants). However, only the two to five years follow-up included the clear possibility of a clinically important effect (putative minimal clinically important difference for this outcome is 10 points).Adverse effects of treatment were reported in one trial only; all four major complications were attributed to the surgical treatment group. Slightly more people in the surgery group had subsequent surgery six to nine years after their primary dislocation (20/87 versus 16/78; RR 1.06, 95% CI 0.59 to 1.89, two studies, 165 participants). Based on an illustrative risk of subsequent surgery in 186 people per 1000 in the non-surgical group, these data equate to 11 more (95% CI 76 fewer to 171 more) people per 1000 having subsequent surgery after primary surgery. AUTHORS' CONCLUSIONS Although there is some evidence to support surgical over non-surgical management of primary patellar dislocation in the short term, the quality of this evidence is very low because of the high risk of bias and the imprecision in the effect estimates. We are therefore very uncertain about the estimate of effect. No trials examined people with recurrent patellar dislocation. Adequately powered, multi-centre, randomised controlled trials, conducted and reported to contemporary standards, are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the anatomical or pathological variations that may be relevant to both choice of these interventions and the natural history of patellar instability. Furthermore, well-designed studies recording adverse events and long-term outcomes are needed.
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Affiliation(s)
- Toby O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Queen's Building, Norwich, Norfolk, UK, NR4 7TJ.
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Vivod G, Verdonk P, Drobnič M. Long-term clinical and radiographic outcome of patello-femoral realignment procedures: a minimum of 15-year follow-up. Knee Surg Sports Traumatol Arthrosc 2014; 22:2747-55. [PMID: 24061714 DOI: 10.1007/s00167-013-2637-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 08/20/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE A retrospective single-centre study was focused on the long-term outcome after different patello-femoral (PF) realignment procedures. METHODS Thirty-nine patients treated for recurrent PF instability were examined after a mean post-operative time of 22.5 years. Their 78 knees were divided into: non-operated knees (NON-OPERATED)-N = 24, isolated proximal procedures (PROXIMAL)-N = 22, isolated distal procedures (DISTAL)-N = 10, and combined procedures (COMBINED)-N = 22. PF-related medical history together with clinical, subjective (KOOS and Kujala scores), and radiographic (Caton-Deschamps PF height index, Kellgren-Lawrence scale for tibio-femoral OA, and Iwano classification for PF OA) evaluation was conducted. RESULTS PF re-dislocation rate was comparable between PROXIMAL (36%), DISTAL (20%), and COMBINED (32%). Isolated proximal procedures revealed less central patella positions (PROXIMAL 64%; DISTAL 90%; COMBINED 95%) and more frequent PF apprehension test (PROXIMAL 82%; DISTAL 40%, COMBINED 50%). KOOS and Kujala scores were similar in all three surgical subgroups, but significantly lower than in NON-OPERATED. Patellas were positioned lower after DISTAL, 0.8 (0.5-1.0) or COMBINED, 0.9 (0.4-1.3). Kellgren-Lawrence scores ≥2 were found in 42% NON-OPERATED, 37% PROXIMAL, 70% DISTAL, and 59% COMBINED, whereas Iwano classification ≥2 was confirmed in 46% NON-OPERATED, 64% PROXIMAL, 80% DISTAL, and 86% COMBINED. CONCLUSIONS High PF re-dislocation rates together with a very high incidence of PF OA indicate that PF realignment strategies used traditionally had failed to reach their long-term expectations. The transfer of tibial tuberosity resulted in more constrained PF joints than isolated proximal procedures which allowed for more residual PF instability. Distal procedures additionally increased the likelihood for tibio-femoral OA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Gregor Vivod
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Iliadis AD, Jaiswal PK, Khan W, Johnstone D. The operative management of patella malalignment. Open Orthop J 2012; 6:327-39. [PMID: 22927893 PMCID: PMC3426825 DOI: 10.2174/1874325001206010327] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 02/27/2012] [Accepted: 03/07/2012] [Indexed: 01/17/2023] Open
Abstract
Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment.Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness.A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.
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Affiliation(s)
| | - Parag Kumar Jaiswal
- The Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
| | - Wasim Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
| | - David Johnstone
- Stoke Manderville Hospital, Aylesbury, Buckinghamshire, HP21 8AL, UK
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Brand RA. 50 years ago in CORR: recurrent dislocating patella: a long-term follow-up study James B. Jones, MD, Kenneth C. Francis, MD, John R. Mahoney, MD CORR 1961;20:230-240. Clin Orthop Relat Res 2012; 470:313-4. [PMID: 21984355 PMCID: PMC3238005 DOI: 10.1007/s11999-011-2125-2] [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: 09/22/2011] [Accepted: 09/28/2011] [Indexed: 01/31/2023]
Affiliation(s)
- Richard A Brand
- Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA, USA.
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Hing CB, Smith TO, Donell S, Song F. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2011:CD008106. [PMID: 22071844 DOI: 10.1002/14651858.cd008106.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patellar dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. Following reduction of the dislocation, conservative rehabilitation with physiotherapy may be used. Since recurrence of dislocation is common, some surgeons have advocated surgical intervention in addition to rehabilitation. OBJECTIVES The purpose of this review was to assess the clinical and radiological outcomes of surgical, compared with non-surgical, interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, ZETOC, Physiotherapy Evidence Database (PEDro), and a variety of other literature databases and trial registries. Corresponding authors were contacted to identify additional studies. Date searched: August 2010. SELECTION CRITERIA Eligible for inclusion were randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating lateral patellar dislocation. DATA COLLECTION AND ANALYSIS Two reviewers independently examined titles and abstracts of each identified study to assess study eligibility, extract data and assess risk of bias. Primary outcomes assessed were the frequency of recurrent dislocation, and validated patient-rated knee or physical function scores. When appropriate, data were pooled. Risk ratios were calculated for dichotomous outcomes, and mean differences for continuous outcomes. MAIN RESULTS Five studies (339 participants) were included. All studies had methodological shortcomings, especially the two quasi-randomised trials that presented a high risk for selection bias. Follow-up was a minimum of two years in two studies and between five and seven years in three studies. There was no significant difference between surgical and non-surgical management of primary (first-time) patellar dislocation in the risk of recurrent dislocation (47/182 versus 53/157; risk ratio 0.81, 95% confidence interval 0.56 to 1.17; 5 trials), Kujala patellofemoral disorder scores (mean difference 3.13, 95% confidence interval -7.34 to 13.59; 5 trials) nor the requirement for subsequent surgery (risk ratio 1.09, 95% CI 0.72 to 1.65; 3 trials). Adverse events were reported by one trial, citing four major complications that occurred in the surgical group. No randomised controlled trials have assessed populations with recurrent patellar dislocation. AUTHORS' CONCLUSIONS There is insufficient high quality evidence to confirm any significant difference in outcome between surgical or non-surgical initial management of people following primary patellar dislocation, and none examining this comparison in people with recurrent patellar dislocation. Adequately powered randomised, multi-centre controlled trials, conducted and reported to contemporary standards are recommended.
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Affiliation(s)
- Caroline B Hing
- Department of Trauma & Orthopaedic Surgery, Watford General Hospital, Watford, UK.
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Smith TO, Song F, Donell ST, Hing CB. Operative versus non-operative management of patellar dislocation. A meta-analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19:988-98. [PMID: 21234544 DOI: 10.1007/s00167-010-1355-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 12/06/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Conservative management of patellar dislocation can result in recurrent instability in up to 60% of patients. Surgery is therefore advocated in an attempt to reduce the incidence of recurrent dislocation and instability. The purpose of this study was to compare the clinical outcomes of operative to non-operative treatment strategies for patients following patellar dislocation. METHODS A systematic review of published and unpublished literature was undertaken. Following data extraction, a meta-analysis was conducted to compare the two treatment strategies. The methodological quality of the literature was assessed using the PEDro critical appraisal tool. RESULTS Eleven studies were included, five randomised controlled trials (RCTs) and six non-RCTs. These assessed 403 patients managed conservatively, compared to 344 managed surgically. The findings of this study indicate that operative management of patellar dislocation is associated with a significantly higher risk of patellofemoral joint osteoarthritis (P=0.04), but a significantly lower risk of subsequent patellar dislocation compared to non-surgical management (P<0.01). CONCLUSIONS The meta-analysis indicates that there may be a difference in the incidence of patellofemoral joint osteoarthritis and rate of subsequent dislocation. However, this finding should currently be interpreted with great caution due to the demonstration of statistically significant publication bias, issues related to the methodological quality of the evidence base, and due to the variety of different surgical interventions currently presented within the literature. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Toby O Smith
- Faculty of Health, University of East Anglia, and Institute of Orthopaedics, Norwich University Hospital, Norwich, NR4 7TJ, UK.
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Endres S, Wilke A. A 10 year follow-up study after Roux-Elmslie-Trillat treatment for cases of patellar instability. BMC Musculoskelet Disord 2011; 12:48. [PMID: 21329530 PMCID: PMC3049144 DOI: 10.1186/1471-2474-12-48] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 02/18/2011] [Indexed: 11/14/2022] Open
Abstract
Background A retrospective study concerning patients presenting with patella instability, treated using a Roux-Elmslie-Trillat reconstruction operation and followed up for 10 years following surgery, is presented. Methods Pre-operative and follow-up radiographic evaluation included the weight-bearing anteroposterior and merchant views. Evaluation was carried out using the Insall-Salvati index, sulcus and congruence angle. The Roux-Elmslie-Trillat reconstruction operation was performed on 18 patients. The clinical evaluation at follow-up was performed using the Knee-Society-Score (KSS) and Tegner-Score. Results Subjective results of the operation were classed as excellent or good in 16 of the 18 patients ten years after surgery; persistent instability of the patella was recorded in only one of the 18 patients. The majority of patients returned to the same level of sporting activity after surgery as they had participated in before injury. Conclusions The Roux-Elmslie-Trillat procedure could be recommended in cases presenting with an increased q-angle, trochlea dysplasia or failed soft tissue surgery. In the present study the majority of patients report a return to previous sporting activity ten years after surgery.
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Affiliation(s)
- Stefan Endres
- Department of Orthopaedic Surgery Elisabeth-Klinik Bigge/Olsberg, Heinrich-Sommer-Strasse 4, 59939 Olsberg, Germany.
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Smith TO, Davies L, Chester R, Clark A, Donell ST. Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review. Physiotherapy 2010; 96:269-81. [DOI: 10.1016/j.physio.2010.02.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 02/10/2010] [Indexed: 02/03/2023]
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18
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Femoral trochleoplasty for recurrent patellar instability: a modified surgical technique and its medium-term results. CURRENT ORTHOPAEDIC PRACTICE 2010. [DOI: 10.1097/bco.0b013e3181b02e49] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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de Andrade MAP, de Abreu e Silva GM, Freire MM, Teixeira LEM. SURGICAL TREATMENT OF PATELLOFEMORAL INSTABILITY. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2009; 44:529-32. [PMID: 27077065 PMCID: PMC4816864 DOI: 10.1016/s2255-4971(15)30153-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Utting MR, Mulford JS, Eldridge JDJ. A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. ACTA ACUST UNITED AC 2008; 90:180-5. [PMID: 18256084 DOI: 10.1302/0301-620x.90b2.20017] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and is an important contributory factor to patellofemoral instability and recurrent dislocation. We studied prospectively a series of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, who were treated by a trochleoplasty by a single surgeon between June 2002 and June 2007. Pre- and post-operative scores were assessed by the patients and a satisfaction questionnaire was completed. Of the 54 patients (59 knees) in the series, 39 (44 knees) were female and 15 (15 knees) were male. Their mean age at surgery was 21 years and 6 months (14 years 4 months to 33 years 11 months). In 40 patients (42 knees) the mean follow-up was for 24 months (12 to 58). One patient was unable to attend for follow-up. An analysis of the results of those patients followed up for at least 12 months showed a statistically significant improvement in outcome (p < 0.001 for all scores). Overall, 50 patients (92.6%) were satisfied with the outcome of their procedure. The early results of trochleoplasty are encouraging in this challenging group of patients.
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Affiliation(s)
- M R Utting
- Winford Unit, Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5BN, UK.
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Sillanpää P, Mattila VM, Visuri T, Mäenpää H, Pihlajamäki H. Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res 2008; 466:1475-84. [PMID: 18347890 PMCID: PMC2384023 DOI: 10.1007/s11999-008-0207-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 02/25/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Recently, medial patellofemoral ligament reconstruction has been emphasized for the treatment of patellar dislocation. This study compared the results of medial patellofemoral ligament reconstruction by adductor magnus tenodesis with distal patellar realignment in patients with recurrent patellar dislocation. Additionally, the development of patellofemoral osteoarthrosis was compared for these two procedures at a median 10-year followup. Between 1994 and 2000, 47 consecutive patients were treated for recurrent patellar dislocation by adductor magnus tenodesis (18 knees) or Roux-Goldthwait procedure (29 knees). Redislocations, subjective symptoms, and functional outcomes were evaluated. Magnetic resonance imaging was performed at followup. The incidence of patellar redislocation after surgery was 7% in the adductor magnus group and 14% in the Roux-Goldthwait group. Median Kujala scores were 88 for the adductor magnus group and 86 for the Roux-Goldthwait group. Magnetic resonance imaging revealed patellofemoral articular cartilage lesions in 22 knees (73.3%) at followup, including 14 (46.6%) with full-thickness cartilage loss. Radiographs revealed patellofemoral osteoarthritis in five patients in the Roux-Goldthwait group and in none of the patients in the adductor magnus group. Adductor magnus tenodesis is a reliable method to treat recurrent patellar dislocation. The medial patellofemoral ligament reconstruction seems to reduce the risk of osteoarthrosis compared with distal realignment surgery. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Petri Sillanpää
- />Centre for Military Medicine, Lahti, Finland , />Research Department, Centre for Military Medicine, Helsinki, Finland , />Kerkkäkatu 5, 33820 Tampere, Finland
| | - Ville M. Mattila
- />Centre for Military Medicine, Lahti, Finland , />Research Department, Centre for Military Medicine, Helsinki, Finland
| | - Tuomo Visuri
- />Centre for Military Medicine, Lahti, Finland , />Department of Orthopaedic Surgery, Central Military Hospital, Helsinki, Finland
| | - Heikki Mäenpää
- />Department of Orthopaedic Surgery, Tampere University Hospital, Tampere, Finland
| | - Harri Pihlajamäki
- />Centre for Military Medicine, Lahti, Finland , />Research Department, Centre for Military Medicine, Helsinki, Finland , />Department of Orthopaedic Surgery, Central Military Hospital, Helsinki, Finland
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Aärimaa V, Ranne J, Mattila K, Rahi K, Virolainen P, Hiltunen A. Patellar tendon shortening after treatment of patellar instability with a patellar tendon medialization procedure. Scand J Med Sci Sports 2007; 18:442-6. [PMID: 18067514 DOI: 10.1111/j.1600-0838.2007.00730.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Patellar instability is a multifactorial disorder. Patella alta is strongly associated with patellar instability. We hypothesize that procedures of the patellar tendon such as medialization may shorten the patellar tendon. In this retrospective study, 41 patients with patellar instability were treated operatively with a patellar tendon medialization procedure. Twenty-eight knees were treated using a modified Roux-Goldthwait method and 16 using a modified Elmslie-Trillat method. The patients were followed 2-7 years after the operation. Pre- and post-operative x-rays were analyzed with particular emphasis on patellar tendon length, patellofemoral congruence angle and osteoarthritis. The final clinical outcome was assessed using the Lysholm score and clinical examination. In both groups patients were generally satisfied with the result of the operation and there was no significant difference in Lysholm scores at follow-up. However, patellofemoral osteoarthritic changes increased in both groups compared with the pre-operative status. The patellar tendon length was reduced in both groups, but significantly, by 7%, in the Roux-Goldthwait group. We conclude that patellar tendon shortens after a Roux-Goldthwait procedure.
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Affiliation(s)
- V Aärimaa
- Department of Orthopaedics and Traumatology, Turku University and University Hospital, Turku, Finland.
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Mulford JS, Wakeley CJ, Eldridge JDJ. Assessment and management of chronic patellofemoral instability. ACTA ACUST UNITED AC 2007; 89:709-16. [PMID: 17613491 DOI: 10.1302/0301-620x.89b6.19064] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.
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Affiliation(s)
- J S Mulford
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, UK
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Servien E, Verdonk PC, Neyret P. Tibial tuberosity transfer for episodic patellar dislocation. Sports Med Arthrosc Rev 2007; 15:61-7. [PMID: 17505319 DOI: 10.1097/jsa.0b013e3180479464] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Numerous surgical techniques have been described to address episodic patellar dislocations. Some of them involve the soft tissues whereas others primarily address a bony correction. Four principal anatomic factors have been identified that increase the risk for episodic patellar dislocations: trochlear dysplasia, patella alta, patellar tilt, and an excessive tibial tubercle-trochlear groove distance. A treatment algorithm has been proposed to correct each of these factors. It includes the tibial tuberosity transfer, which is able to correct both a patella alta and an excessive tibial tubercle-trochlear groove distance. The tibial tuberosity can be transferred distally or medially or more frequently a combination of both. It will realign the extensor mechanism and increase patellofemoral stability. This procedure may be associated with a medial patellofemoral ligament reconstruction in case of excessive patellar tilt or rarely with a trochleoplasty for major abnormal patellar maltracking.
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Affiliation(s)
- Elvire Servien
- Department of Orthopaedic Surgery, Centre Livet, Centre Hospital Universitaire, Lyon, France.
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Abstract
Patellar instability is defined by clinical and radiologic criteria. The surgical treatment is aimed at restoring the congruence of the patellofemoral articulation and correcting extensor mechanism malalignment, to prevent recurrence of dislocation. The standard soft-tissue procedures are lateral release and vastus medialis advancement and medial patello femoral ligament plasty. Bony procedures are frequently performed in addition to soft-tissue surgery, to realign the extensor mechanism by means of tibial tubercle medialization, or to correct the patellar index in patella alta. In a smaller number of patients, the trochlea may be reshaped, by elevating the lateral trochlear facet or by lowering the floor of the sulcus. The morphologic abnormalities encountered are studied and quantified in the light of preoperative investigations (conventional radiographs and computed tomography), and addressed at surgery using the technique or techniques most appropriate for the management of the individual patient's pattern.
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Affiliation(s)
- David Dejour
- Corolyon Clinique Sauvegarde, Lyon Cedex, France.
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Krause F, Kolling C, Brantschen R, Sieber HP. Mittelfristige Ergebnisse der Vastus-medialis-obliquus-Plastik bei lateraler Patellaluxation. DER ORTHOPADE 2006; 35:94-101. [PMID: 16193343 DOI: 10.1007/s00132-005-0871-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Progressive retropatellar arthrosis is often seen in dated rigid distal realignment (i.e. osteotomy of tuberositas) at long-term follow-ups. Therefore, operations for lateral dislocation of the patella are still discussed controversially. Dynamic, proximal realignments seem to have lower rates of arthrosis but higher rates of redislocation. Recently, in anatomic and biomechanic studies, the m. vastus medialis obliquus (vmo) was found to be one of the most important proximal restraints to lateral dislocation of the patella.A total of 28 patients (mean age 21.5 years) were treated between 1994 and 2003 with a plasty of the vmo for lateral patellar dislocation. The technique was performed for most etiologies of femoropatellar instability. For this proximal soft tissue technique, the muscle tendon is detached from its patellar insertion. Subsequently, the tendon is reinserted at the patella 10-15 mm more distally and fixed with Mitek anchors. Full weight bearing in extension is possible immediately after surgery. An active vastus medialis training is started after 6 weeks. Of the patients, 27 were evaluated clinically and radiologically in 2004 (a mean of 5 years postoperatively). A total of 83% of the patients estimated the result to be good or excellent, 10% were satisfied and 7% were discontent. The mean Lysholm-Knee-Score was 83.1 points. Two patients suffered a patella redislocation (7%). A statistically significant improvement of the congruence angle was noted in the radiographs, even in medium-term controls. In 89% of the cases no or only little retropatellar arthrosis was observed. These 5 year results are comparable to those of other techniques for distal or proximal realignments. The rate of redislocation was below average. Compared to the rate of retropatellar arthrosis in long-term results of rigid distal realignment, our patients demonstrated a relative low rate after 5 years. We attribute this to the minimal interference in physiological joint mechanics and to the restored anatomy. In terms of future long-term results, our findings are promising. The idea of a proximal dynamic stabilization and the causal operative approach at the origin of pathology using vmo-plasty was confirmed in recent anatomic and biomechanic studies. Over or under correction of soft tissues could be adapted. More rigid techniques of distal realignment do not allow an adaptation to this extent and can lead to prearthrotic hyperpression in the medial femoropatellar and femorotibial joints.
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Affiliation(s)
- F Krause
- Orthopädische Chirurgie, Inselspital Bern, Schweiz.
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Grelsamer RP. Definition of eponyms. Knee Surg Sports Traumatol Arthrosc 1996; 4:64. [PMID: 8819067 DOI: 10.1007/bf01566001] [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] [Indexed: 02/02/2023]
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