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Howard RA, Morales JA, Ordaz A, Bryan TP, Edmonds EW. Postoperative Access and Compliance Following Medial Patellofemoral Ligament Reconstruction in Hispanic Adolescents Mirrors the Non-Hispanic Adolescent Population. J Pediatr Orthop 2024; 44:e767-e772. [PMID: 38907588 DOI: 10.1097/bpo.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
BACKGROUND Disparity in surgical care of patellar instability patients has not been fully investigated in the adolescent Hispanic population. This demographic has been shown to have differences in their care, including a lower rate of surgical treatment for patellar instability. Socioeconomic factors have been cited as a factor that influences patient outcomes and its relationship with ethnicity in context of patellar instability has not been evaluated. METHODS Review performed of patients <19 years of age who underwent MPFL reconstruction between September 2008 and December 2015. Demographics, patient median household income data, and clinical variables were collected. Generalized linear mixed model (GLMM) with subject as random effects factor was utilized to evaluate differences between ethnicity groups due to nonindependence of data. It was then expanded to incorporate interactions between ethnicity and income. RESULTS Ninety-five patellar dislocation events met criteria in 85 adolescents (mean age: 15.5 y). Thirty-four (40%) adolescents identified as Hispanic. In univariate analysis no differences were found between Hispanic and non-Hispanic patients. The multivariate GLMM demonstrated a significant interaction between ethnicity and income. The Hispanic group in the >100% State median income category had the highest rate of postoperative clinic appointments attended ( P =0.019). The Hispanic group in the <100% State median income category had the lowest rate of physical therapy appointments attended ( P =0.044). No differences were observed for duration of follow-up ( P =0.57) or final Kujala score ( P =0.75). CONCLUSIONS Hispanic ethnicity alone is not associated with inferior postoperative management after MPFL reconstruction in adolescents. However, when socioeconomic status is considered, Hispanic patients of lower-income backgrounds are found to have lower compliance with postoperative rehab recommendations. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Roland A Howard
- Department of Orthopedic Surgery, University of California San Diego
| | - Jose A Morales
- School of Medicine, University of California Riverside, Riverside, CA
| | - Angel Ordaz
- Department of Orthopedic Surgery, University of California San Diego
| | - Tracey P Bryan
- Division of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego
| | - Eric W Edmonds
- Department of Orthopedic Surgery, University of California San Diego
- Division of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego
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Tedeschi R, Platano D, Giorgi F, Donati D. To Operate or Not? Evaluating the Best Approach for First-Time Patellar Dislocations: A Review. J Clin Med 2024; 13:5434. [PMID: 39336921 PMCID: PMC11432519 DOI: 10.3390/jcm13185434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/09/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Background: The optimal management of first-time patellar dislocations remains a subject of debate. While surgical intervention is often recommended to reduce the risk of redislocation, the benefits over conservative treatment regarding knee function and complication rates are not clearly established. This systematic review aims to compare the effectiveness of surgical versus conservative treatment in preventing redislocation and improving knee function, while also considering complication rates. Methods: A comprehensive search of databases, including PubMed, Scopus, and Web of Science, was conducted up to July 2024. Seven randomized controlled trials involving 411 participants were included. The primary outcome was the redislocation rate, with secondary outcomes including knee function, complication rates, and the need for re-interventions. The quality of the studies was assessed using the PEDro scale. Results: Surgical treatment generally resulted in lower redislocation rates compared to conservative management. However, the improvement in knee function was inconsistent, with some studies showing no significant differences or even favoring conservative treatment. Surgical intervention was associated with a higher risk of complications and re-interventions, particularly in older studies with less advanced techniques. Conclusions: Surgical intervention appears effective in reducing redislocation rates but comes with a risk of complications. Conservative treatment remains a viable option, particularly for patients with lower activity levels or higher surgical risks. The decision between surgical and conservative management should be individualized, taking into account patient-specific factors and potential risks. Further high-quality research is needed to provide more definitive guidance.
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Affiliation(s)
- Roberto Tedeschi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40136 Bologna, Italy
| | - Daniela Platano
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40136 Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federica Giorgi
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Institute of Neurological Sciences, Sciences of Bologna, Via Altura 3, 40124 Bologna, Italy
| | - Danilo Donati
- Physical Therapy and Rehabilitation Unit, Policlinico di Modena, 41125 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
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Özdemir U, Çinar BM, Türker M, Uyar AÇ, Serttaş MF, Akar A, Şükür E, Kochai A. Ellipsoidal patellar bone tunnel fixation with Toggleloc suspension system for medial patellofemoral ligament reconstruction: A 5 years follow-up. Medicine (Baltimore) 2024; 103:e38379. [PMID: 38941440 DOI: 10.1097/md.0000000000038379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the clinical and radiological features of the patella fixation technique using Toggleloc suspension system in a single ellipsoidal blind patellar tunnel during medial patellofemoral ligament (MPFL) reconstruction. METHODS This study included 52 patients (25 men, 27 women) who underwent MPFL reconstruction using a semitendinosus tendon graft. The graft was fixed to the ellipsoidal single blind tunnel opened on the medial side of the patella with an endobutton and was fixed to the femoral tunnel by using bioabsorbable screw. Clinical scores (Kujala score, Lysholm score, Tegner activity score and the visual analog scale [VAS] score) were evaluated preoperatively and at the end-follow up. Preoperative and postoperative radiological measurements (trochlea depth, sulcus angle, patellar height, patellar congruence angle, patellar tilt angle and lateral patellofemoral angle) were evaluated with X-ray (Merchant X-ray, anteroposterior and lateral radiography) and computed tomography (CT) of the knee. RESULTS Postoperative patellar redislocation or subluxation was not observed in any patient. Patellar congruence angle, patellar tilt angle and lateral patellofemoral angle mean values were found to return to normal values in the postoperative period and the results were statistically significant. Also statistically significant improvement in all clinical scores postoperatively. According to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) on lateral radiography of the knee at 30° flexion, patellar height decreased in the postoperative period statistically significant. The CDI was above 1.3 in 17 (%32) of our patients. Thirteen of these values decreased to normal values. No radiological progression of patellofemoral osteoarthritis was observed in all patients at the final follow-up evaluation. CONCLUSION In cases of patellofemoral instability, fixation of the tendon graft in blind ellipsoid tunnel using the Toggleloc suspension system provides satisfactory patellar graft fixation strength, significant functional improvement and a low failure rate.
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Affiliation(s)
- Uğur Özdemir
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Bandırma Onyedi Eylül University Faculty of Medicine, Balıkesir, Turkey
| | - Bekir Murat Çinar
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Mehmet Türker
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Ahmet Çağri Uyar
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Kocaeli City Hospital, Kocaeli, Turkey
| | - Muhammed Fatih Serttaş
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Abdülhalim Akar
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Emsey Hospital Hastanesi, İstanbul, Turkey
| | - Erhan Şükür
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Alauddin Kochai
- Consultant Orthopaedic Surgeon. Department of Orthopedics and Traumatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
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Waters TL, Miller EM, Beck EC, Rider DE, Waterman BR. Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction. Arthrosc Sports Med Rehabil 2024; 6:100890. [PMID: 38333569 PMCID: PMC10851212 DOI: 10.1016/j.asmr.2024.100890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/07/2024] [Indexed: 02/10/2024] Open
Abstract
Purpose To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up. Methods A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation. Results A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm). Conclusions MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | - Evan M. Miller
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward C. Beck
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Danielle E. Rider
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, U.S.A
| | - Brian R. Waterman
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Guo H, Zhou K, Sun Z, Feng A, Qin S, Liu L, Sun R, Wang X. Morphological Changes of the Posterior Femoral Condyle After Medial Patellar Retinaculum Plasty in Skeletally Immature Patients With Recurrent Patellar Dislocation and Trochlear Dysplasia. Orthop J Sports Med 2024; 12:23259671231225671. [PMID: 38304055 PMCID: PMC10832434 DOI: 10.1177/23259671231225671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 02/03/2024] Open
Abstract
Background Surgical correction for recurrent patellar dislocation (RPD) can improve femoral trochlear morphology; nonetheless, the effects of surgical correction on femoral condyle morphology are unclear. Purpose To investigate the morphological changes in the posterior femoral condyle in skeletally immature patients with RPD and trochlear dysplasia (TD) after surgical correction. Study Design Cohort study; Level of evidence, 3. Methods A total of 20 skeletally immature patients with bilateral RPD and TD were included in this study. For each patient, the knee that was dislocated more frequently or had sustained a recent injury was treated with medial patellar retinaculum plasty (group S; n = 20 knees), and the asymptomatic or only occasionally dislocated contralateral knee was treated conservatively (group C; n = 20 knees). The lengths of the anterior medial and lateral femoral condyles and the lengths of the posterior medial and lateral femoral condyles were evaluated preoperatively and at the final follow-up. Trochlear morphological characteristics, tibial tuberosity-trochlear groove distance, and patellar tilt angle were compared between preoperative and final follow-up values with the 2-sample paired Student t test and were compared between groups S and C with the independent-samples t test. Results The mean follow-up time was 60.7 ± 4.8 months. No knee in group S experienced a redislocation, whereas 80% (16/20) of knees in group C experienced a dislocation. There were significant group differences in the ratio of the posterior medial femoral condyle (PMFC) to the posterior lateral femoral condyle (PLFC) (group S, 1.08 ± 0.05; group C, 1.14 ± 0.06; P = .042). There was no significant difference in the ratio of the anterior lateral femoral condyle to the anterior medial femoral condyle (group S, 1.16 ± 0.13; group C, 1.18 ± 0.09; P = .635). In group S, all trochlear morphological characteristics and patellofemoral joint characteristics improved compared with preoperatively (P≤ .047 for all). In addition, all values significantly differed between groups S and C at the final follow-up (P≤ .044 for all). Conclusion The study findings demonstrated that the morphology of the posterior femoral condyle in skeletally immature patients with bilateral RPD and TD changes after surgical correction, with the PLFC growing faster than the PMFC.
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Affiliation(s)
- Hailong Guo
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kezhen Zhou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhiwen Sun
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ao Feng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Shiqi Qin
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lei Liu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ran Sun
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaofeng Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Alshaban RM, Ghaddaf AA, Alghamdi DM, Aghashami A, Alqrni A, Alyasi AA, Bogari H, Qadi S. Operative versus non-operative management of primary patellar dislocation: A systematic review and network meta-analysis. Injury 2023; 54:110926. [PMID: 37473507 DOI: 10.1016/j.injury.2023.110926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Acute patellar dislocation is a common knee injury in adolescents and adults that is associated with a high incidence of medial patellofemoral ligament (MPFL) injuries. The aim of this network meta-analysis was to compare the different operative and non-operative protocols for the management of primary patellar dislocation (PPD). METHODS We searched Medline, Embase, and CENTRAL databases. We included randomized controlled trials (RCTs) that compared operative and non-operative protocols for adolescent or adult patients with acute traumatic PPD. We sought to evaluate the clinical and functional outcomes of each management protocol by considering the results of Kujala score, Tegner activity score, redislocation rate, and subluxation rate. The effectiveness of the different management protocols was measured through frequentist network meta-analysis, using the Netmeta statistical package in R software. All treatment protocols were ranked using the netrank function, yielding P scores. RESULTS A total of 10 RCTs were deemed eligible. As per P-scores, open MPFL repair yielded the highest effectiveness with respect to Kujala score (P=0.81) and lowest odds for redislocation (P=0.14) whereas arthroscopic MPFL repair yielded the highest effectiveness with respect to Tegner activity score (P=0.85) and lowest odds for subluxation (P=0.21). Arthroscopic MPFL repair showed a significant reduction in redislocation and subluxation rate. CONCLUSION This network meta-analysis demonstrated arthroscopic MPFL repair is the most effective treatment protocol for the management of acute primary patellar dislocation.
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Affiliation(s)
- Raneem M Alshaban
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Dalia M Alghamdi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Afnan Aghashami
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ali Alqrni
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulrahman A Alyasi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan Bogari
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Sara Qadi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Orthopedic Surgery Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Yoo JD, Huh MH, Lee CW, Roh YH, D’Lima DD, Shin YS. Medial patellofemoral ligament reconstruction appears to be a better treatment than repair, proximal realignment, or conservative management for primary patellar dislocation: A network meta-analysis. Medicine (Baltimore) 2023; 102:e35251. [PMID: 37773862 PMCID: PMC10545352 DOI: 10.1097/md.0000000000035251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to compare the functional outcomes and re-dislocation rates of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, combined proximal realignment (CPR), and conservative management for primary patellar dislocation by conducting a systematic literature search of the available studies. The hypothesis was that MPFL repair and MPFL reconstruction would be better options for treating primary patellar dislocation. METHODS Randomized controlled trials or prospective studies of primary patellar dislocation treated with MPFL reconstruction, MPFL repair, CPR, or conservative management were identified from the MEDLINE, EMBASE, and the Cochrane Library databases through December 31, 2021. A total of 626 patients met the prespecified inclusion criteria. The methodological quality of each study was assessed using a risk of bias table, Detsky quality index, and Newcastle-Ottawa Scale. The end-point data collected included comparisons of the mean in functional scores on knee outcomes scales and the number of patients who experienced re-dislocation. A network meta-analysis of the relevant literature was performed to investigate which treatment showed better outcomes. RESULTS In total, 10 trials were included in this study. There was no statistically significant difference in the subgroup analysis in terms of the functional outcomes among MPFL reconstruction, MPFL repair, CPR, and conservative management. However, MPFL reconstruction showed statistically significantly better outcomes than MPFL repair, CPR, or conservative management in terms of the re-dislocation rate. Additionally, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair even though there was no significant difference (0.24, 95% confidence interval: 0.02-2.91). CONCLUSION Using a network meta-analysis, this meta-analysis showed that there was no significant difference in functional outcomes in a subgroup analysis. In re-dislocation subgroup analysis, MPFL repair and MPFL reconstruction produced significantly better results than other treatments. Also, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair.
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Affiliation(s)
- Jae-Doo Yoo
- Department of Orthopedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Min-Hwan Huh
- Department of Orthopedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Chan-Woo Lee
- Department of Orthopedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Young-Hak Roh
- Department of Orthopedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Darryl D. D’Lima
- Shiley Center for Orthopaedic Research and Education, Scripps Health, LA Jolla, CA
| | - Young-Soo Shin
- Department of Orthopedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Lee DY, Kang DG, Jo HS, Heo SJ, Bae JH, Hwang SC. A systematic review and meta-analysis comparing conservative and surgical treatments for acute patellar dislocation in children and adolescents. Knee Surg Relat Res 2023; 35:18. [PMID: 37349852 PMCID: PMC10286373 DOI: 10.1186/s43019-023-00189-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/02/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE This study sought to clarify treatment evidence to treat patellar dislocation by evaluating which treatment could yield better improvement of clinical outcomes for acute patellar dislocation in children and adolescents 18 years of age or younger. MATERIALS AND METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials electronic databases were searched for relevant articles comparing clinical outcomes of conservative and surgical treatments for acute patellar dislocation in children and adolescents published from March 2008 to August 2022. Data searching, extraction, analysis, and quality assessment were performed on the basis of the Cochrane Collaboration guidelines. The quality assessment of each study was investigated using the Physiotherapy Evidence Database (PEDro) critical appraisal scoring system and Newcastle-Ottawa Quality Assessment Scale scores. To calculate the overall combined effect size for each outcome, Review Manager Version 5.3 (The Cochrane Collaboration, Software Update, Oxford) was employed. RESULTS Three randomized controlled trials (RCTs) and one prospective study were investigated. In terms of pain [mean difference (MD) 6.59, 95% confidence interval (CI) 1.73-11.45, I2 0%], there were significantly better outcomes in conservative group. Nevertheless, there were no significant differences in any evaluated outcomes such as redislocation [risk ratio (RR) 1.36, 95% CI 0.72-2.54, I2 65%], Kujala score (MD 3.92, 95% CI -0.17 to 8.01, I2 0%), Tegner score (MD 1.04, 95% CI -0.04 to 2.11, I2 71%), or subjective results (RR 0.99, 95% CI 0.74-1.34, I2 33%) between conservative and surgical treatment groups. CONCLUSIONS Despite better pain outcomes with conservative group, the present study revealed no significant differences in clinical outcomes between conservative treatment and surgical treatment in children and adolescents with acute patellar dislocation. Since there are no significant differences in clinical outcomes between the two groups, routine surgical treatment is not advocated for treating acute patellar dislocation in children and adolescents.
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Affiliation(s)
- Dong-Yeong Lee
- Department of Orthopaedic Surgery, Barun Hospital, Jinju, Republic of Korea
| | - Dong-Geun Kang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Changwon Hospital, Changwon, Republic of Korea
| | - Ho-Seung Jo
- Department of Orthopaedic Surgery, SMG Yeonse Hospital, Changwon, Republic of Korea
| | - Se-Joon Heo
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Ji-Ho Bae
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea
| | - Sun-Chul Hwang
- Department of Orthopaedic Surgery, College of Medicine and Gyeongsang National University and Hospital, Jinju, Republic of Korea.
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Jiang J, Yi Z, Li J, Liu Y, Xia Y, Wu M. Medial Patellofemoral Ligament Reconstruction is Preferred to Repair or Reefing for First-Time Patellar Dislocation: A Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:177-188. [PMID: 36777132 PMCID: PMC9880132 DOI: 10.1007/s43465-022-00770-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
Purpose The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing for patients with first-time patellar dislocation. Methods Databases of PubMed, EMBASE, Cochrane Library and Web of Science were searched up to May 8, 2022. Only articles treating first-time patellar dislocation with MPFL reconstruction, MPFL repair and medial reefing were included in the analysis. Eligible identification, data extraction, quality assessment and statistical analysis were performed by two independent reviewers. The primary outcome measures were the incidences of postoperatively redislocation and reoperation. The second outcomes were the Kujala functional score and complications (including infection, osteoarthritis, and loss of range of motion). Results Twenty-two studies involving 668 patients met the inclusion criteria. Of which, four studies involving 126 patients were in MPFL reconstruction group, ten studies involving 220 patients in MPFL repair group and 9 studies involving 322 patients in medial reefing group. Our results showed that the MPFL reconstruction (1.8%, 95% CI - 0.5 to 4.0%) had a significantly lower rate of postoperative redislocation and reoperation rate than the MPFL repair (15.4%, 95% CI 5.2-25.7%) and medial reefing (18.0%, 95% CI 9.3-26.7%). Besides, no significant differences were found in the Kujala score and complication rate among the three treatments. Conclusion The available evidence demonstrated that MPFL reconstruction could achieve significantly lower redislocation rate and reoperation rate than MPFL repair and medial reefing after first-time patella dislocation. Furthermore, there was not enough evidence to reveal that MPFL reconstruction provided better functional outcome compared with MPFL repair and medial reefing. MPFL reconstruction is a preferred surgical treatment for patients with first-time patellar dislocation. Level of Evidence Level IV, systematic review of Level I-IV.
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Affiliation(s)
- Jin Jiang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Zhi Yi
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Junmin Li
- Department of Pharmacy, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yan Liu
- School of Pharmacy, Lanzhou University, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
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Smith TO, Gaukroger A, Metcalfe A, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2023; 1:CD008106. [PMID: 36692346 PMCID: PMC9872769 DOI: 10.1002/14651858.cd008106.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patellar (knee cap) dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. It affects up to 42/100,000 people, and is most prevalent in those aged 20 to 30 years old. It is uncertain whether surgical or non-surgical treatment is the best approach. This is important as recurrent dislocation occurs in up to 40% of people who experience a first time (primary) dislocation. This can reduce quality of life and as a result people have to modify their lifestyle. This review is needed to determine whether surgical or non-surgical treatment should be offered to people after patellar dislocation. OBJECTIVES To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL, Physiotherapy Evidence Database and trial registries in December 2021. We contacted corresponding authors to identify additional studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating primary or recurrent lateral patellar dislocation in adults or children. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were recurrent patellar dislocation, and patient-rated knee and physical function scores. Our secondary outcomes were health-related quality of life, return to former activities, knee pain during activity or at rest, adverse events, patient-reported satisfaction, patient-reported knee instability symptoms and subsequent requirement for knee surgery. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 10 studies (eight randomised controlled trials (RCTs) and two quasi-RCTs) of 519 participants with patellar dislocation. The mean ages in the individual studies ranged from 13.0 to 27.2 years. Four studies included children, mainly adolescents, as well as adults; two only recruited children. Study follow-up ranged from one to 14 years. We are unsure of the evidence for all outcomes in this review because we judged the certainty of the evidence to be very low. We downgraded each outcome by three levels. Reasons included imprecision (when fewer than 100 events were reported or the confidence interval (CI) indicated appreciable benefits as well as harms), risk of bias (when studies were at high risk of performance, detection and attrition bias), and inconsistency (in the event that pooled analysis included high levels of statistical heterogeneity). We are uncertain whether surgery lowers the risk of recurrent dislocation following primary patellar dislocation compared with non-surgical management at two to nine year follow-up. Based on an illustrative risk of recurrent dislocation in 348 people per 1000 in the non-surgical group, we found that 157 fewer people per 1000 (95% CI 209 fewer to 87 fewer) had recurrent dislocation between two and nine years after surgery (8 studies, 438 participants). We are uncertain whether surgery improves patient-rated knee and function scores. Studies measured this outcome using different scales (the Tegner activity scale, Knee Injury and Osteoarthritis Outcome Score, Lysholm, Kujala Patellofemoral Disorders score and Hughston visual analogue scale). The most frequently reported score was the Kujala Patellofemoral Disorders score. This indicated people in the surgical group had a mean score of 5.73 points higher at two to nine year follow-up (95% CI 2.91 lower to 14.37 higher; 7 studies, 401 participants). On this 100-point scale, higher scores indicate better function, and a change score of 10 points is considered to be clinically meaningful; therefore, this CI includes a possible meaningful improvement. We are uncertain whether surgery increases the risk of adverse events. Based on an assumed risk of overall incidence of complications during the first two years in 277 people out of 1000 in the non-surgical group, 335 more people per 1000 (95% CI 75 fewer to 723 more) had an adverse event in the surgery group (2 studies, 144 participants). Three studies (176 participants) assessed participant satisfaction at two to nine year follow-up, reporting little difference between groups. Based on an assumed risk of 763 per 1000 non-surgical participants reporting excellent or good outcomes, seven more participants per 1000 (95% CI 199 fewer to 237 more) reported excellent or good satisfaction. Four studies (256 participants) assessed recurrent patellar subluxation at two to nine year follow-up. Based on an assumed risk of patellar subluxation in 292 out of 1000 in the non-surgical group, 73 fewer people per 1000 (95% CI 146 fewer to 35 more) had patellar subluxation as a result of surgery. Slightly more people had subsequent surgery in the non-surgical group. Pooled two to nine year follow-up data from three trials (195 participants) indicated that, based on an assumed risk of subsequent surgery in 215 people per 1000 in the non-surgical group, 118 fewer people per 1000 (95% CI 200 fewer to 372 more) had subsequent surgery after primary surgery. AUTHORS' CONCLUSIONS We are uncertain whether surgery improves outcome compared to non-surgical management as the certainty of the evidence was very low. No sufficiently powered trial has examined people with recurrent patellar dislocation. Adequately powered, multicentre, randomised trials are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the pathological variations that may be relevant to both choice of these interventions.
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Affiliation(s)
- Toby O Smith
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andrew Gaukroger
- Trauma and Orthopaedics, St George's University Hospital NHS trust, London, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Caroline B Hing
- Department of Trauma and Orthopaedic Surgery, St George's Hospital, London, UK
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11
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Migliorini F, Baroncini A, Bell A, Weber C, Hildebrand F, Maffulli N. Surgical strategies for chondral defects of the patellofemoral joint: a systematic review. J Orthop Surg Res 2022; 17:524. [PMID: 36471319 PMCID: PMC9720953 DOI: 10.1186/s13018-022-03419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/24/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND The management of chondral defects of the patellofemoral joint is debated, and definitive evidence is lacking. This study systematically updated and summarised the current literature on the surgical management of isolated chondral defects of the patellofemoral joint, discussing techniques, outcome, pitfalls, and new frontiers. METHODS This systematic review was conducted according to the 2020 PRISMA statement. In August 2022, PubMed, Web of Science, Google Scholar, and Embase databases were accessed with no time constrain. All the clinical studies investigating the surgical management of chondral defects of the patellofemoral joint were retrieved. Articles which reported data on patients with advanced to severe osteoarthritis were not eligible. Only studies with a minimum 24 months follow-up were considered. Studies which mixed results of patellofemoral and tibiofemoral joints were not considered. RESULTS Data from 10 studies (692 procedures) were retrieved. The mean follow-up was 46.9 ± 18.2 months. The mean age of the patients was 34.0 ± 6.1 years, and the mean BMI was 25.9 ± 0.8 kg/m2. The mean duration of symptoms before the index surgery was 81.0 ± 24.0 months. The mean defect size was 3.8 ± 0.8 cm2. All the PROMs improved from baseline to last follow-up: VAS 0-10 (P = 0.04), Tegner (P = 0.02), Lysholm (P = 0.03), and International Knee Documentation Committee (P = 0.03). The rate of hypertrophy was 5.6% (14 of 251), the rate of progression to total knee arthroplasty was 2.4% (2 of 83), the rate of revision was 16.9% (29 of 136), and the rate of failure was 13.0% (16 of 123). CONCLUSION Current surgical strategies may be effective to improve symptoms deriving from chondral defects of the patellofemoral joint. The limited and heterogeneous data included for analysis impact negatively the results of the present study. Further clinical studies are strongly required to define surgical indications and outcomes, and the most suitable technique.
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Affiliation(s)
- Filippo Migliorini
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany ,Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Alice Baroncini
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Christian Weber
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hildebrand
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Nicola Maffulli
- grid.11780.3f0000 0004 1937 0335Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA Italy ,grid.9757.c0000 0004 0415 6205School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB England ,grid.4868.20000 0001 2171 1133Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London, E1 4DG England
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12
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Zheng ET, Kocher MS, Wilson BR, Hussain ZB, Nunally KD, Yen YM, Kramer DE, Micheli LJ, Heyworth BE. Descriptive Epidemiology of a Surgical Patellofemoral Instability Population of 492 Patients. Orthop J Sports Med 2022; 10:23259671221108174. [PMID: 35859643 PMCID: PMC9289910 DOI: 10.1177/23259671221108174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patellofemoral instability (PFI) occurs most commonly in pediatric and
adolescent patients, with evolving indications for surgery and changes in
surgical techniques over the past decade. Purpose: To characterize the demographic, clinical, and radiologic characteristics of
a large cohort of patients undergoing PFI surgery and investigate
longitudinal trends in techniques utilized over a 10-year period at a
tertiary-care academic center. Study Design: Case series; Level of evidence, 4. Methods: Electronic medical records of patients younger than 25 years of age who
underwent primary surgery for lateral PFI from 2008 to 2017 at a single
center by 1 of 5 different sports medicine surgeons were retrospectively
reviewed. Demographic, clinical, and radiographic parameters of instability
were analyzed. Routine surgical techniques included medial retinacular
plication/reefing/repair (MRP), medial patellofemoral ligament
reconstruction (MPFLR), tibial tubercle osteotomy (TTO), or a combination
thereof, with or without lateral retinacular release (LR) or lateral
retinacular lengthening (LRL). Exclusion criteria, selected for potentially
altering routine surgical indications or techniques, included
fixed/syndromic PFI, a formally diagnosed collagen disorder, cases in which
a chondral/osteochondral shear fragment underwent fixation or was >1 cm
in diameter, and body mass index >30 kg/m2. Results: Of the 492 study patients (556 knees; 71% female; median age, 15.2 years; 38%
open physes), 88% were athletes, with the most common sports participated in
being soccer, basketball, dance, football, gymnastics, and
baseball/softball. While 91% of the cohort had recurrent dislocations, the
9% with primary dislocations were more likely to have small osteochondral
fractures/loose bodies (P < .001). Female patients were
younger (P = .002), with greater patellar tilt
(P = .005) than male patients. Utilization of MPFLR and
TTO increased significantly over the study period, while use of MRP+LR
decreased. Conclusion: Most patients younger than 25 years of age who underwent PFI surgery were
skeletally immature, female, and athletes and had recurrent dislocations.
The <10% who had primary dislocations and underwent surgery were likely
to have osteochondral fractures. Surgical techniques have changed
significantly over time, with increasing use of TTO and MPFLR, while the use
of MRP+LR/LRL has significantly decreased.
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Affiliation(s)
- Evan T Zheng
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin R Wilson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kianna D Nunally
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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13
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Medial patellofemoral ligament reconstruction is superior to active rehabilitation in protecting against further patella dislocations. Knee Surg Sports Traumatol Arthrosc 2022; 30:3428-3437. [PMID: 35347375 PMCID: PMC9464184 DOI: 10.1007/s00167-022-06934-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Isolated reconstruction of the medial patellofemoral ligament (MPFL-R) has become the predominant stabilizing procedure in the treatment of recurrent lateral patellar dislocation (LPD). To minimize the risk of re-dislocations, isolated MPFL-R is recommended in patients with no significant trochlea dysplasia and tibial tuberosity trochlear groove distance < 20 mm on computed tomography (CT). Incidentally, these criteria are the same that are used to identify first time LPD patients where conservative treatment is recommended. The purpose of this study was therefore to compare MPFL-R with active rehabilitation for patients with recurrent LPD (RLPD) in absence of the above mentioned underlying anatomical high-risk factors for further patellar dislocations. METHODS RLPD-patients aged 12-30 without underlying anatomical high-risk factors for further LPD were randomized into treatment either with isolated MPFL-R or active rehabilitation provided and instructed by a physiotherapist. All patients underwent diagnostic arthroscopy for concomitant problems. The main outcome measure was persistent patellar instability at 12 months. Knee function at baseline and 12 months was asses using the following patient reported outcomes measures (PROMS); KOOS, Kujala, Cincinnati knee rating, Lysholm score and Noyes sports activity rating scale. RESULTS Between 2010 and 2019, 61 patients were included in the study (MPFL-R, N = 30, Controls, N = 31). Persistent patellar instability at 12 months was reported by 13 (41.9%) controls, versus 2 (6.7%) in the MPFL-group (RR 6.3 (95% CI 1.5-25.5). No statistically significant differences in activity level were found between the MPFL-group and the Controls at neither baseline nor follow up. The patients with persistent instability at 12 months did not score significantly lower on any of the PROMs compared to their stable peers, regardless of study group. CONCLUSION Patients with recurrent patellar dislocations have a six-fold increased risk of persistent patellar instability if treated with active rehabilitation alone, compared to MPFL-R in combination with active rehabilitation, even in the absence of significant anatomical risk factors. Active rehabilitation of the knee without MPFL-R improves patient reported knee function after one year, but does not protect against persistent patellar instability.
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14
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Migliorini F, Marsilio E, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. Chondral and Soft Tissue Injuries Associated to Acute Patellar Dislocation: A Systematic Review. Life (Basel) 2021; 11:life11121360. [PMID: 34947891 PMCID: PMC8706453 DOI: 10.3390/life11121360] [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] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Chondral and soft tissue injuries can be associated with first time patellar dislocation, but it is unclear how common they are, and which tissues are affected. A systematic review of the literature was performed to investigate the frequency, location, and extent of chondral and medial patellofemoral ligament (MPFL) injuries in patients following first time patellar dislocation. METHODS This systematic review was conducted according to the PRISMA guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in November 2021. All the published clinical studies reporting the frequency, location, and extent of soft tissue lesions following first time patellar dislocation were accessed. Studies reporting data on habitual, congenital, or recurrent patellofemoral instability were excluded. RESULTS Data from 42 articles (2254 patients, mean age 21.6 ± 7.3 years) were retrieved. Ninety-eight percent of patients who experienced first time patellar dislocation demonstrated MPFL rupture at MRI. Forty-eight percent of MPFL ruptures were located at the patellar side, 34% at the femoral insertion site, and 18% in the midportion. Eighty-five percent of patients showed signs of patellar chondral damage at MRI, and trochlear chondral injuries were evidenced in 47% of patients. Intra-articular loose bodies were observed in 11.5% of patients. At arthroscopy, the medial facet and the crest of the patella more commonly exhibited chondral lesions than the lateral facet and femoral trochlea. CONCLUSIONS Most patients suffer chondral damage and MPFL tears following after a first time patellar dislocation.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Emanuela Marsilio
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Cuozzo
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Oliva
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Jörg Eschweiler
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Frank Hildebrand
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Nicola Maffulli
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London E1 4DG, UK
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST5 5BG, UK
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15
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Zhao X, Zhang H. Biomechanical Comparison of 2 Patellar Fixation Techniques in Medial Patellofemoral Ligament Reconstruction: Transosseous Sutures vs Suture Anchors. Orthop J Sports Med 2021; 9:23259671211041404. [PMID: 34692878 PMCID: PMC8529315 DOI: 10.1177/23259671211041404] [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: 04/10/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Multiple techniques for fixing a graft to the patella in medial patellofemoral ligament (MPFL) reconstruction have been described; however, no single technique has been shown to be superior to another. Purpose/Hypothesis The purpose of this study was to compare the biomechanical performance of 2 different patellar fixation techniques: suture anchor (SA) and transosseous suture (TS) fixation. The hypothesis was that there would be no significant differences between the groups in ultimate failure load, stiffness, or elongation. Study Design Controlled laboratory study. Methods In this study, a new TS technique was biomechanically compared with the SA technique for MPFL reconstruction using 24 fresh-frozen mature porcine patellae and porcine flexor profundus tendons. The specimens were randomized into 2 groups undergoing MPFL reconstruction using either the SA technique or the TS technique (n = 12 per group). Fixation with TS was completed using 3 No. 2 UltraBraid sutures and three 2-mm transosseous tunnels. SA reconstruction was completed using 2 parallel 3.5-mm titanium SAs with 2 No. 2 UltraBraid sutures. We preconditioned each graft using a force between 5 and 20 N before cyclic loading. Then, the specimens were biomechanically tested (1000 cycles; 5-100 N; 1 Hz) and loaded under tension at 200 mm/min until failure. The ultimate failure load, stiffness, elongation, and failure mode were recorded for each specimen. The Shapiro-Wilk test and independent t tests were used to assess the data. Results The TS technique resulted in a significantly higher mean failure load than did the SA technique (496.18 ± 93.15 vs 399.43 ± 105.35 N; P = .03). The TS technique resulted in less stiffness than did the SA technique (55.42 ± 7.92 vs 72.11 ± 10.64 N/mm; P < .01). There was no significant difference between the groups in elongation. None of the graft fixation/patellar complexes failed during cyclic testing in either group. During the load-to-failure test, the most common mode of failure in the SA group was an anchor being pulled out of the bone, whereas that in the TS group was rupture of the suture material. Conclusion MPFL reconstruction with 3 TSs provided a higher load to failure than did the commonly used fixation method involving SAs.
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Affiliation(s)
- Xin Zhao
- First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hangzhou Zhang
- Department of Orthopedics; Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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16
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Fomin S, Gauffin H, Kvist J. Short-term recovery of physical activity and knee function after an acute knee injury. BMJ Open Sport Exerc Med 2020; 6:e000950. [PMID: 33437496 PMCID: PMC7780533 DOI: 10.1136/bmjsem-2020-000950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives To describe self-reported knee function, participation in physical activity and the number of knee surgeries at 3 and 6 months following acute knee injury. Methods Prospective cohort study. Participants, aged 15–40 years with an acute knee injury sustained no more than 6 weeks prior to inclusion, were recruited. There were 279 participants with ACL injury and 101 participants with other acute knee injuries included. Follow-up questionnaires were sent at 3 and 6 months after injury. Demographic information, activity participation, International Knee Documentation Committee subjective knee form (IKDC-SKF) and the Single Assessment Numeric Evaluation (SANE) score were collected. Additional knee injuries were obtained from self-report and medical charts. Results The IKDC-SKF, SANE and physical activity participation were reduced at 3-month and 6-month follow-up. The number of participants who achieved health-promoting physical activity levels was reduced by 50% at 6-month follow-up compared with before injury. Seventeen per cent of participants with ACL injury and 41% of participants with other acute knee injuries had returned to their preinjury physical activity at 6 months. Participants with ACL injury reported worse knee function, lower physical activity participation and had more surgeries (128 surgeries, including 109 ACL-reconstructions) compared with participants with other acute knee injuries (six surgeries). Conclusion Acute knee injuries, including ACL injuries, affected self-reported knee function and physical activity participation for at least 6 months after index injury. More research is needed to understand how best to help people with acute knee injuries return to physical activity and achieve satisfactory knee function.
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Affiliation(s)
- Sanne Fomin
- Unit of Physioptherapy, Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | - Håkan Gauffin
- Orthopaedics. Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Joanna Kvist
- Unit of Physioptherapy, Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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17
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Zhang K, Jiang H, Li J, Fu W. Comparison Between Surgical and Nonsurgical Treatment for Primary Patellar Dislocations in Adolescents: A Systematic Review and Meta-analysis of Comparative Studies. Orthop J Sports Med 2020; 8:2325967120946446. [PMID: 33015209 PMCID: PMC7513014 DOI: 10.1177/2325967120946446] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Whether surgical or nonsurgical management is more appropriate for primary
patellar dislocations (PPDs) in adolescents (younger than 18 years) remains
controversial. Purpose: To compare the clinical outcomes of surgical versus nonsurgical treatment for
adolescents and children with PPDs. Study Design: Systematic review; Level of evidence, 3. Methods: There were 2 reviewers who independently searched the PubMed, Embase, Ovid,
and Cochrane databases for English-language studies of randomized controlled
trials (RCTs), quasi-RCTs, and observational studies comparing surgical with
nonsurgical treatment for PPDs. The primary outcomes were redislocations,
the Kujala score, and the Knee injury and Osteoarthritis Outcome Score
(KOOS), and the secondary outcome was subsequent surgery. Results: A total of 6 studies were included in our systematic review and
meta-analysis. Among patients younger than 18 years, surgery was associated
with a lower redislocation rate compared with nonsurgical treatment within 5
years of treatment (risk ratio [RR], 0.58 [95% CI, 0.37-0.91];
P = .02; I2 = 47%) but not beyond 5 years (RR, 0.80 [95% CI, 0.59-1.07];
P = .14; I2 = 34%). However, surgery resulted in worse Kujala and KOOS
scores compared with nonsurgical treatment. Yet, the treatment difference
between the 2 groups tended to decrease over time. Conclusion: The available evidence suggests that for adolescents with PPDs, surgery was
superior to nonsurgical treatment in the short term to reduce the
redislocation rate but resulted in poorer outcomes of knee function based on
the Kujala and KOOS scores. However, the superiority of either surgical or
nonsurgical treatment in adolescents did not appear to persist in the long
term.
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Affiliation(s)
- Kaibo Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Jiang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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18
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Song SY, Kim TS, Seo YJ. Initial conservative treatment of osteochondral fracture of the patella following first-time patellar dislocation. BMC Musculoskelet Disord 2020; 21:617. [PMID: 32943024 PMCID: PMC7499907 DOI: 10.1186/s12891-020-03641-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/10/2020] [Indexed: 01/03/2023] Open
Abstract
Background There has been no gold standard of the initial treatment strategy for acute patellar dislocation (APD) with osteochondral fracture (OCF). Hence the study aim is firstly, to review and compare clinical outcomes of patients who underwent conservative treatment for APD with or without OCF. Secondly, to characterize the location and size of fracture fragment. Methods Sixty-nine consecutive patients who were retrospectively evaluated after first-time APD over a 2- year period were divided into two groups (group 1 (n = 24): APD with OCF and group 2 (n = 45): APD only). Magnetic resonance imaging (MRI) was used to assess patients with APD and OCF from the medial patella. All patients were treated with a supervised course of immobilization followed by progressive range of motion and strength exercise protocol. History of a recurrent dislocation, radiologic and functional scores were analyzed. Results Redislocation rate was 31.2% in group 1 and 26.6% in group 2, showing no significant difference between the two groups (p = 0.690). Intergroup differences in terms of final Kujala and IKDC scores were not significant (p = 0.117 and p = 0.283, respectively). Fracture sites of the patella in group 1 were classified as follows: patellar medial margin (12), inferomedial facet (7), and inferomedial facet involving central ridge (5). In the subgroup of patient with OCF of the inferomedial facet of the patella, the fragments were found in the lateral gutter and did not cause pain or mechanical symptoms. Thus, loose body removal was not performed. However, all five patients with large OCF involving the central ridge of the patella failed non-operative treatment with recurrent dislocations, ultimately requiring fragment refixation and medial retinacular imbrication. Conclusions First, APD patients with OCFs of medial margin or inferomedial facet showed similar redislocation rates and functional knee scores with those without OCFs after conservative treatment. Second, initial conservative treatment failed in some APD patients with large OCF, especially when OCFs were fractured from inferomedial facet involving central ridge. Surgery should be considered with this type.
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Affiliation(s)
- Si Young Song
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Republic of Korea
| | - Tae-Soung Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Republic of Korea
| | - Young-Jin Seo
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Republic of Korea.
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Xing X, Shi H, Feng S. Does surgical treatment produce better outcomes than conservative treatment for acute primary patellar dislocations? A meta-analysis of 10 randomized controlled trials. J Orthop Surg Res 2020; 15:118. [PMID: 32209111 PMCID: PMC7093955 DOI: 10.1186/s13018-020-01634-5] [Citation(s) in RCA: 16] [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: 11/14/2019] [Accepted: 03/12/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose The objective of this study was to conduct the latest meta-analysis of randomized controlled trials (RCTs) that compare clinical results between surgery and conservative therapy of acute primary patellar dislocation (APPD), focusing on medial patellofemoral ligament (MPFL) reconstruction. Methods We performed a literature search in Embase, The Cochrane Library, PubMed, and Medline to identify RCTs comparing APPD surgical treatment with conservative treatment from the establishment of each database to January 2019. The methodological quality of each RCT was assessed independently by the two authors through the Cochrane Collaboration’s “Risk of Bias” tool. Mean differences of continuous variables and risk ratios of dichotomous variables were computed for the pooled data analyses. The I2 statistic and the χ2 test were used to evaluate heterogeneity, with the significance level set at I2 > 50% or P < 0.10. Results Ten RCTs with a sum of 569 patients (297 receiving surgical treatment and 263 receiving conservative treatment) met the inclusion criteria for meta-analysis. Pooled data analysis showed no statistical difference in the field of subluxation rate, Kujala score, patient satisfaction, and frequency of reoperation between the two groups. Tegner activity score and recurrent dislocation rate in the conservative group were significantly higher than those in the surgically treated group. Conclusions Conservative treatment may produce better outcomes than surgery for APPD in consideration of Tegner activity score. However, in view of limited research available, the interpretation of the discoveries should be cautious. More convincing evidence is required to confirm the effect of MPFL reconstruction.
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Affiliation(s)
- Xuewu Xing
- Department of Orthopaedics, Tianjin First Central Hospital, First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Hongyu Shi
- Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin, China
| | - Shiqing Feng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin, China.
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Migliorini F, Driessen A, Quack V, Gatz M, Tingart M, Eschweiler J. Surgical versus conservative treatment for first patellofemoral dislocations: a meta-analysis of clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:771-780. [PMID: 32048045 DOI: 10.1007/s00590-020-02638-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/05/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The first approach for acute patellar dislocation is still a debated topic. The purpose of the present study was to perform a meta-analysis evaluating the outcomes of the surgical approach compared to the conservative treatments for primary acute patellar dislocation. We hypothesize that a prompt surgical treatment may lead to better outcomes in terms of re-dislocations and quality of life. METHODS This meta-analysis was performed according to the PRISMA guidelines. All the prospective clinical trials comparing surgical and conservative treatment for first acute patellofemoral dislocation were included in this study. For the methodological quality assessment, the PEDro appraisal score was adopted. For the risk of publication bias, the funnel plot was performed. The statistical analysis was performed using the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen). RESULTS The funnel plot detected a low risk of publication bias. According to the PEDro score, the methodological quality assessment was good. Data from 654 patients were collected, undergoing a mean of 53.8 ± 48.4 month follow-up. A total of 311 patients (17.66 ± 4.1 years old) were analyzed in the surgery group and 291 patients (19.25 ± 4.5 years old) in the conservative ones. The mean Kujala score resulted in greater favor of the surgery group (MD: 9.99%; P = 0.006). The analysis of the comparison of re-dislocations resulted in favor of the surgery group (OR: 0.41; P < 0.0001). The analysis of the comparison of persistent joint instability resulted in favor of the surgery group (OR: 0.41; P < 0.0001). CONCLUSIONS Data from the present study encourage a prompt surgical approach for the first patellofemoral dislocation.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Arne Driessen
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Valentin Quack
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Matthias Gatz
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedic Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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Bulgheroni E, Vasso M, Losco M, Di Giacomo G, Benigni G, Bertoldi L, Schiavone Panni A. Management of the First Patellar Dislocation: A Narrative Review. JOINTS 2019; 7:107-114. [PMID: 34195538 PMCID: PMC8236325 DOI: 10.1055/s-0039-3401817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/04/2019] [Indexed: 01/11/2023]
Abstract
First patellar dislocation is a common injury of the knee, involving often adolescents and the active population. The consequences of the first episode can be various and potentially disabling. Among these, acute patellar dislocation can often result in recurrent patellar instability. Recurrent patellar instability is certainly multifactorial but depends primarily on the injury of the medial patellofemoral ligament (MPFL), the major soft-tissue stabilizer of the patella. Some classifications are extremely useful in establishing the diagnosis and therapy in patellofemoral disease, in particular in terms of instability. Among those, Henri Dejour and WARPS (weak atraumatic risky anatomy pain and subluxation)/STAID (strong traumatic anatomy normal instability and dislocation) classifications are certainly the most frequently used. There is no clear agreement on the management of the first patellar dislocation. A conservative approach seems to be the first choice in most of cases, but the presence of patellar displacement or osteochondral fractures makes surgery mandatory at the beginning. In addition, there is no clear consensus on which surgical strategy should be used to approach first dislocation, in relation to the possible variation in location of the MPFL injury, and to the eventual presence of preexisting predisposing factors for patellar instability. MPFL reconstruction may theoretically be more reliable than repair, while there is no clear evidence available that osseous abnormality should be addressed after the first episode of patellar dislocation. A narrative review was conducted to report the etiology, the diagnosis and all the possible treatment options of the first patellar dislocation. Modern classifications of the patellofemoral instability were also presented.
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Affiliation(s)
- Erica Bulgheroni
- Department of Orthopaedic and Trauma Surgery, Santa Chiara Hospital, Trento, Italy
| | - Michele Vasso
- Multidisciplinary Department of Medico-Surgical and Dentistry Specialties, "Luigi Vanvitelli" University, Naples, Italy
| | - Michele Losco
- Department of Orthopaedic and Trauma Surgery, AOU Careggi, Florence, Italy
| | | | - Giorgio Benigni
- Department of Orthopaedic and Trauma Surgery, Santa Chiara Hospital, Trento, Italy
| | - Luciano Bertoldi
- Department of Orthopaedic and Trauma Surgery, Santa Chiara Hospital, Trento, Italy
| | - Alfredo Schiavone Panni
- Multidisciplinary Department of Medico-Surgical and Dentistry Specialties, "Luigi Vanvitelli" University, Naples, Italy
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Pagliazzi G, Napoli F, Previtali D, Filardo G, Zaffagnini S, Candrian C. A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation. Arthroscopy 2019; 35:2469-2481. [PMID: 31395189 DOI: 10.1016/j.arthro.2019.03.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/17/2019] [Accepted: 03/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE II, meta-analysis of level I and level II randomized clinical trials.
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Affiliation(s)
- Gherardo Pagliazzi
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Francesca Napoli
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland; Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
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Yang F, Guo W, Wang Q, Zhu Z, Guan C, Zhao S, Yuan B. Surgical versus nonsurgical treatment of primary acute patellar dislocation: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16338. [PMID: 31335681 PMCID: PMC6708831 DOI: 10.1097/md.0000000000016338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND To systematically review the efficacy of surgical versus nonsurgical treatment for acute patellar dislocation. MATERIALS AND METHODS PubMed, Cochrane, and Embase were searched up to February 12, 2019. After removing duplicates, preliminary screening, and reading the full texts, we finally selected 16 articles, including 11 randomized controlled trials and 5 cohort studies. The quality of the enrolled studies was evaluated by Jadad score or Newcastle-Ottawa scale. Meta-analyses were performed using odds ratio (OR) and standardized mean difference (SMD) as effect variables. The clinical parameters assessed included mean Kujala score, rate of redislocation, incidence of patellar subluxation, patient satisfaction, and visual analog scale (VAS) for pain. Evidence levels were determined using GRADE profile. RESULTS The 16 included studies involved 918 cases, 418 in the surgical group and 500 in the nonsurgical group. The results of the meta-analysis showed higher mean Kujala score (SMD = 0.79, 95% confidence interval [CI] [0.3, 1.28], P = .002) and lower rate of redislocation (OR = 0.44, 95% CI [0.3, 0.63], P < .00001) in the surgical group than the nonsurgical group, but showed insignificant differences in the incidence of patellar subluxation (OR = 0.61, 95% CI [0.36, 1.03], P = .06), satisfaction of patients (OR = 1.44, 95% CI [0.64, 3.25], P = .38), and VAS (SMD = 0.84, 95% CI [-0.36, 9.03], P = .84). CONCLUSION For patients with primary acute patellar dislocation, surgical treatment produces a higher mean Kujala score and a lower rate of redislocation than nonsurgical treatment.
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Affiliation(s)
- Fan Yang
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Wenlai Guo
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center
| | - Qian Wang
- Otolaryngology Head and Neck Surgery. The First Hospital of Jilin University, Changchun, China
| | - Zhe Zhu
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center
| | - Congying Guan
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Shishun Zhao
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Baoming Yuan
- Department of Orthopedics. The Second Hospital of Jilin University
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Surgical medial patellofemoral ligament reconstruction versus non-surgical treatment of acute primary patellar dislocation: a prospective controlled trial. INTERNATIONAL ORTHOPAEDICS 2018; 43:1495-1501. [DOI: 10.1007/s00264-018-4243-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/14/2018] [Indexed: 12/28/2022]
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Lee DY, Park YJ, Song SY, Hwang SC, Park JS, Kang DG. Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis. Arthroscopy 2018; 34:3082-3093.e1. [PMID: 30301628 DOI: 10.1016/j.arthro.2018.06.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 06/20/2018] [Accepted: 06/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the techniques yields better improvement in stability and functional recovery for patellar dislocation. METHODS The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus electronic databases were searched for relevant articles comparing the outcomes of medial patellofemoral ligament (MPFL) treatment published up until August 2017. Data searching, extraction, analysis, and quality assessment were performed based on The Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome values in various techniques. For results with high heterogeneity, 95% prediction intervals (PIs) were also investigated. RESULTS Eleven clinical studies were investigated. In patients with primary patellar dislocation, there were no significant differences in all evaluated outcomes between the conservative and surgical treatment groups. For patients with recurrent patellar dislocation, MPFL reconstruction was associated with a favorable Kujala score (mean difference, -8.91; 95% confidence interval, -14.05 to -3.77; I2 = 94%; 95% PI, -9.64 to -8.1) and Lysholm score (mean difference, -13.51; 95% confidence interval, -21.35 to -5.68; I2 = 96%; 95% PI, -14.86 to -12.16) when compared with soft tissue realignment surgery. CONCLUSIONS Although surgical treatment of the MPFL for primary patellar dislocation is not superior to conservative treatment in restoring knee function and clinical outcomes, MPFL reconstruction is associated with more favorable clinical outcomes compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. Double-bundle MPFL reconstruction seems to provide more favorable outcomes than single-bundle MPFL reconstruction, but this finding should be interpreted with caution because the evidence levels were low and were from only a few studies. LEVEL OF EVIDENCE Level III, meta-analysis.
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Affiliation(s)
- Dong-Yeong Lee
- Department of Orthopaedic Surgery, Armed Forces Daegu Hospital, Gyeongsan, Republic of Korea
| | - Young-Jin Park
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Sang-Youn Song
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Sun-Chul Hwang
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin-Sung Park
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Dong-Geun Kang
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea.
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Operative Versus Nonoperative Treatment After Acute Patellar Dislocation: Which Is More Effective at Reducing Recurrence in Adolescents? J Sport Rehabil 2018; 27:601-604. [PMID: 28872404 DOI: 10.1123/jsr.2017-0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinical Scenario: Acute patellar dislocations during adolescence often lead to future patellar instability. Two common treatment options include nonoperative treatment or operative repair of injured structures. Focused Clinical Question: In adolescents with acute patellar dislocation, how does operative stabilization compare with nonoperative treatment for reducing dislocation recurrence? Summary of Key Findings: Three studies were included: 2 randomized controlled trials and 1 nonrandomized study. All studies compared operative and nonoperative treatment outcomes in adolescents who experienced an acute patellar dislocation. Each study included nonoperative treatment such as patellar bracing and quadriceps strengthening. The operative treatments utilized in each study included lateral retinacular release and medial retinacular repair. All 3 of the studies included a follow-up of at least 6 years. Two of the studies concluded there to be no significant difference between treatment groups regarding redislocation rate, pain, and function. The third study reported a lower redislocation rate following operative treatment. Clinical Bottom Line: Reviewed evidence suggests that outcomes are similar when comparing operative and nonoperative treatment approaches with little agreement as to which is the optimal plan of action. Strength of Recommendation: One level II randomized controlled trial and a level III nonrandomized study suggest that patellar dislocation recurrence rates are similar among operative and nonoperative treatment approaches, while another level II randomized controlled trial suggests that an operative approach is superior.
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The Fragility of Statistically Significant Results in Pediatric Orthopaedic Randomized Controlled Trials as Quantified by the Fragility Index: A Systematic Review. J Pediatr Orthop 2018; 38:e418-e423. [PMID: 29979332 DOI: 10.1097/bpo.0000000000001201] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The randomized controlled trial (RCT) is the gold standard study design allowing critical comparison of clinical outcomes while minimizing bias. Traditionally clinical trials are evaluated through statistical significance, expressed by P-values and confidence intervals. However, until recently, the robustness of a study's conclusions has been given little attention. A new metric, the fragility index, quantifies the number of patients theoretically required to switch outcomes in order to reverse the study conclusions. The primary aim of our work was to determine the fragility index of RCTs in the pediatric orthopaedic literature. The secondary aim was to determine study factors associated with lower fragility index. METHODS Pubmed and Embase were systematically searched for pediatric orthopaedic RCTs published September 1, 2006 to September 1, 2016. Two independent reviewers screened titles, abstracts, and manuscripts to identify studies published in English involving 2 treatment arms. Trials without dichotomous primary or secondary outcomes or with patients >18 years were excluded. Data were extracted from each eligible article in duplicate and the fragility index was determined using Fisher exact test, with previously published methods. Univariate analysis was used to determine factors associated with lower fragility index. RESULTS Seventeen trials were eligible for inclusion. The median treatment arm size was 58 and overall sample size was 116 patients. The median fragility index was 3 (range, 0 to 18). A fragility index of 3 means that just 3 patients would need to switch treatment outcomes in order for the trial results to become statistically nonsignificant. In 1 study, the number of patients lost to follow-up exceeded the fragility index, such that the study conclusions could be completely reversed purely depending on the outcomes of the patients lost to follow-up. Lower fragility index was associated with smaller patient sample sizes and greater P-values. CONCLUSIONS The fragility index is a useful adjunct metric to the P-value and confidence intervals, allowing analysis of the robustness of study conclusions. RCTs in pediatric orthopaedics often have small sample sizes, many with low fragility indices. Future efforts could focus on encouraging institutional collaboration and patient recruitment with the ultimate goal of improving RCT sample sizes, and potentially improving the robustness of RCT results. LEVEL OF EVIDENCE Level I.
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Reider B. Kneecapped! Am J Sports Med 2018; 46:2325-2327. [PMID: 30063399 DOI: 10.1177/0363546518788542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Askenberger M, Bengtsson Moström E, Ekström W, Arendt EA, Hellsten A, Mikkelsen C, Janarv PM. Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial. Am J Sports Med 2018; 46:2328-2340. [PMID: 29847145 DOI: 10.1177/0363546518770616] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. PURPOSE (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. RESULTS The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. CONCLUSION Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).
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Affiliation(s)
- Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital, Solna, Sweden
| | - Eva Bengtsson Moström
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital, Solna, Sweden
| | - Wilhelmina Ekström
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | | | - Christina Mikkelsen
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.,Capio Artro Clinic, Stockholm, Sweden
| | - Per-Mats Janarv
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.,Capio Artro Clinic, Stockholm, Sweden
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Treatment of Primary Acute Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature. Clin J Sport Med 2017; 27:511-523. [PMID: 28107220 DOI: 10.1097/jsm.0000000000000410] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate clinical outcomes, rate of redislocation, and complications after conservative or surgical procedures used to treat primary acute patellar dislocation. METHODS A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patella," "dislocation," "treatment," "acute," "primary" was performed. The following data were extracted: demographics, chondral defects and soft tissue lesions, outcome measurements, type of management, recurrence of instability, and complications. RESULTS A total of 2134 knees in 2086 patients were included, with an average age at dislocation of 20.3 years. The average Kujula score was 75.6 for patients treated conservatively and 88.7 for patients undergoing surgical treatment in the short-medium follow-up (less than 5 years); the average Kujula score was 87.5 for patients treated conservatively and 86.6 for patients undergoing surgical treatment in the long-term follow-up (more than 5 years). The rate of recurrence was significantly lower in the surgical group (25%) than in the conservative group (36.4%). The overall complication rate was 6.5% (29 of 441 knees) in the surgical management group. No complications were reported for patients treated conservatively. CONCLUSIONS Surgical treatment of primary acute patellar dislocation leads to significantly lower rate of redislocation and provides better short-medium clinical outcomes, whereas in the long-term follow-up, results of patients treated conservatively were as good as those of surgical patients. Further randomized controlled trials, describing anatomical abnormalities and soft-tissue integrity that may influence the choice of treatment, are needed. LEVEL OF EVIDENCE Systematic review, level IV.
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Nwachukwu BU, So C, Schairer WW, Shubin Stein BE, Strickland SM, Green DW, Dodwell ER. Economic Decision Model for First-Time Traumatic Patellar Dislocations in Adolescents. Am J Sports Med 2017; 45:2267-2275. [PMID: 28463547 DOI: 10.1177/0363546517703347] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The surgical management of traumatic patellar dislocations in adolescents is associated with a lower rate of recurrent dislocations compared with nonoperative care. However, the attendant cost of surgery and the quality-of-life benefit of a surgical treatment strategy are unclear. PURPOSE To compare the cost-utility of 3 management strategies for acute first-time patellar dislocations in adolescents: (1) nonoperative treatment only, (2) initial nonoperative treatment with surgery only for recurrent dislocations, and (3) immediate surgery. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A 10-year state-transition Markov model was constructed to compare the cost-utility of the 3 index treatment protocols. Utilities used to define health states were derived from a telephone interview of 60 adolescents with a history of acute patellar dislocations. The probability of transition between each health state was informed by the available literature. Direct costs were estimated using a statewide ambulatory surgery database, and indirect costs were estimated based on parental lost productivity. Effectiveness was expressed in quality-adjusted life years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS In the base case for our model, nonoperative treatment only was the least costly ($7300) but also the least effective (5.30 QALYs); initial nonoperative treatment with delayed surgery cost $10,500 for a 5.93 QALY benefit, while immediate surgical treatment cost $17,100 and provided 6.32 QALY benefits. Compared with nonoperative treatment only, initial nonoperative treatment with delayed surgery was associated with an ICER of $5100 per QALY. When immediate surgery was compared with a strategy of delayed surgery, immediate surgery provided incremental benefits at an ICER of $17,000 per QALY. The model was sensitive to the probability of surgical versus nonoperative treatment to achieve a full return to preinjury activity versus an intermediate lower state. When the probability of achieving a full return to preinjury activity with initial nonoperative treatment exceeds 47.5% (compared with 34.2% in the base case), then initial nonoperative treatment with delayed surgery is preferred to immediate surgery. Similarly, when the probability of achieving a full return to full preinjury activity with surgery falls below 51% (compared with 64% in the base case), then delayed surgery after initial nonoperative treatment is preferred. CONCLUSION Immediate surgery and delayed surgical treatment are both cost-effective treatment options; however, immediate surgical treatment provides the highest QALY gains within a 10-year time horizon. Our model sensitivity analysis highlights the role of optimizing functional and quality-of-life benefits in the treatment of acute traumatic patellar dislocations. These findings have implications for clinical guidelines and policy decisions relating to adolescent patellar dislocations.
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Affiliation(s)
- Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Conan So
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Beth E Shubin Stein
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Sabrina M Strickland
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Emily R Dodwell
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Vetrano M, Oliva F, Bisicchia S, Bossa M, De Carli A, Di Lorenzo L, Erroi D, Forte A, Foti C, Frizziero A, Gasparre G, Via AG, Innocenti B, Longo UG, Mahmoud A, Masiero S, Mazza D, Natali S, Notarangelo C, Osti L, Padulo J, Pellicciari L, Perroni F, Piccirilli E, Ramponi C, Salvatore G, Panni AS, Suarez T, Tarantino U, Vittadini F, Vulpiani MC, Ferretti A, Maffulli N. I.S.Mu.L.T. first-time patellar dislocation guidelines. Muscles Ligaments Tendons J 2017; 7:1-10. [PMID: 28717605 DOI: 10.11138/mltj/2017.7.1.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary traumatic patellar dislocation is common, particularly in young active individuals. A consensus on its management is still lacking. The present work provides easily accessible guidelines to be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care and rationalize the use of resources. LEVEL OF EVIDENCE Ia.
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Affiliation(s)
- Mario Vetrano
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Salvatore Bisicchia
- Department of Orthopaedic Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Michela Bossa
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Angelo De Carli
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Di Lorenzo
- Rehabilitation Unit, Neuroscience Department, "RUMMO" Hospital, Benevento, Italy.,Biomedical Research Centre, Gruppo Forte, Salerno, Italy
| | - Davide Erroi
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Alfonso Forte
- Biomedical Research Centre, Gruppo Forte, Salerno, Italy
| | - Calogero Foti
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Giuseppe Gasparre
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Alessio Giai Via
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), École Polytechnique de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Umile Giuseppe Longo
- Department of Orthopedic and Traumatology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Asmaa Mahmoud
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Daniele Mazza
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Simone Natali
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Christian Notarangelo
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Leonardo Osti
- Unit of Arthroscopy and Sports Trauma Surgery, Hesperia Hospital, Modena, Italy
| | - Johnny Padulo
- University eCampus, Novedrate, Italy; Tunisian Research Laboratory "Sports Performance Optimization", National Center of Medicine and Science in Sport, Tunis, Tunisia; Faculty of Kinesiology, University of Split, Split, Croatia
| | - Leonardo Pellicciari
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Fabrizio Perroni
- School of Exercise and Sport Sciences (SUISM), Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Piccirilli
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Carlo Ramponi
- Sport Physical Therapist, Kinè Physiotherapic Center, Conegliano, Italy
| | - Giuseppe Salvatore
- Department of Orthopedic and Traumatology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Alfredo Schiavone Panni
- Multidisciplinary Department of Medical-Surgical and Dental Specialty, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Tania Suarez
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Filippo Vittadini
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Maria Chiara Vulpiani
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Abstract
Patellar instabilities are the most common knee pathologies during growth. Congenital dislocations are rare. Extensive, early soft tissue releases relocate the extensor mechanism and may enable normal development of the femoro-patellar anatomy.Conservative management is the preferred strategy after a 'first-time' traumatic dislocation. In cases with concomitant anatomical predisposing factors such as trochlear dysplasia, malalignment, malrotation or ligamentous laxity, surgical reconstruction must be considered. The same applies to recurrent dislocations with pain, a sense of instability or re-dislocations which may also lead to functional compensatory mechanisms (quadriceps-avoiding gait in knee extension) or cartilaginous lesions with subsequent patello-femoral osteoarthritis. The decision-making process guiding surgical re-alignment includes analysis with standard radiographs and MRI of the trochlear groove, joint cartilage and medial patello-femoral ligament (MPFL). Careful evaluation of dynamic and static stabilisers is essential: the medial patello-femoral ligament provides stability during the first 20° of flexion, and the trochlear groove thereafter.Excessive femoral anteversion, general ligamentous laxity with increased femoro-tibial rotation, patella alta and increased distance between the tibial tuberosity and the trochlear groove must also be taken into account and surgically corrected.In cases with ongoing dislocations during skeletal immaturity, soft tissue procedures must suffice: reconstruction of the medial patello-femoral ligament as a standalone procedure or in conjuction with more complex distal realignment of the quadriceps mechanism may lead to a permanent stable result, or at least buys time until a definitive bony procedure is performed. Cite this article: Hasler CC, Studer D. Patella instability in children and adolescents. EFORT Open Rev 2016;1:160-166. DOI: 10.1302/2058-5241.1.000018.
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Optimized cartilage visualization using 7-T sodium ((23)Na) imaging after patella dislocation. Knee Surg Sports Traumatol Arthrosc 2016; 24:1601-9. [PMID: 25429766 DOI: 10.1007/s00167-014-3455-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Retropatellar cartilage lesions often occur in the course of recurrent patella dislocation. Aim of this study was to develop a more detailed method for examining cartilage tissue, in order to reduce patient discomfort and time of care. METHODS For detailed diagnosing, a 7-T MRI of the knee joint and patella was performed in nine patients, with mean age of 26.4 years, after patella dislocation to measure the cartilage content in three different regions of interest of the patella. Axial sodium ((23)Na) images were derived from an optimized 3D GRE sequence on a 7-T MR scanner. Morphological cartilage grading was performed, and sodium signal-to-noise ratio (SNR) values were calculated. Mean global sodium values and SNR were compared between patients and volunteers. RESULTS Two out of nine patients showed a maximum cartilage defect of International Cartilage Repair Society (ICRS) grade 3, three of grade 2, three of grade 1, and one patient showed no cartilage defect. The mean SNR in sodium images for cartilage was 13.4 ± 2.5 in patients and 14.6 ± 3.7 in volunteers (n.s.). A significant negative correlation between age and global sodium SNR for cartilage was found in the medial facet (R = -0.512; R (2) = 0.26; p = 0.030). Mixed-model ANOVA yielded a marked decrease of the sodium SNR, with increasing grade of cartilage lesions (p < 0.001). CONCLUSIONS Utilization of the (23)Na MR imaging will make earlier detection of alterations to the patella cartilage after dislocation possible and will help prevent subsequent disease due to start adequate therapy earlier in the rehabilitation process. LEVEL OF EVIDENCE II.
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Nwachukwu BU, So C, Schairer WW, Green DW, Dodwell ER. Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24:760-7. [PMID: 26704809 DOI: 10.1007/s00167-015-3948-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/15/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE The goal of this study was to perform a comparative review to determine whether there is a significant difference in the rate of repeat dislocation and clinical outcome between surgical and conservative management of acute patellar dislocation in children and adolescents. METHODS A systematic review of the MEDLINE database was performed. English-language clinical outcome studies with a primary outcome/treatment specific to acute patella dislocation in a paediatric population were included. Eleven studies met inclusion criteria; Chi-square analysis, independent t tests and weighted mean pooled cohort statistics were performed where appropriate. RESULTS A total of 470 conservatively managed and 157 operatively treated knees were included. Conservatively managed patients were on average 17.0 years and had a mean follow-up of 3.9 years; surgically managed patients were on average 16.1 years and had a mean follow-up of 4.7 years. Conservatively managed knees had a 31% rate of recurrent dislocation rate compared to 22% in surgical knees (p = 0.04). Trochlear dysplasia and skeletal immaturity confer greater risk for recurrent instability. Surgical treatment may provide clinically important quality of life and sporting benefit. CONCLUSIONS Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Conan So
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- University of Maryland School of Medicine, 620 W. Lexington St, Baltimore, MD, 21201, USA
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Daniel W Green
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Emily R Dodwell
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2015. [PMID: 26202017 DOI: 10.1007/s00264-015-2856-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to determine the efficacy of surgical and conservative treatment in the prevention of recurrence after primary patellar dislocation. METHODS Studies were searched on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINHAL from their inception to April 2015. All randomized controlled clinical trials comparing surgical versus conservative treatment after first patellar dislocation were included. Primary outcomes were: recurrent dislocation, subluxation, overall instability and subsequent surgery. Secondary outcomes included imaging, and subjective and objective clinical assessment tools. Methodological quality of the studies was assessed using Cochrane Collaboration's "Risk of Bias" tool. Pooled analyses were reported as risk ratio (RR) using a random effects model. Continuous data were reported as standardized mean difference (SMD) and 95 % confidence intervals (CIs). Heterogeneity was assessed using I². RESULTS Nine studies were included in the meta-analyses. Methodological quality of the studies was moderate to low. Meta-analyses showed that surgical treatment significantly reduces the redislocation rate (RR = 0.62; 95% CI = 0.39, 0.98, p = 0.04) and provides better results on Hughston VAS score (SMD = -0.32; 95% CI = -0.61, -0.03; p = 0.03) and running (OR = -0.52; 95% CI = 0.31, 0.88; p = 0.01). Conservative treatment showed less occurrence of minor complications (OR = 3.46; 95% CI = 2.08, 5.77; p = 0.01) and better results in the figure-of-8 run test (SMD = 0.42; 95% CI = 0.06, 0.77; p = 0.02) and in the squat down test (SMD = -0.45; 95% CI = -0.81, -0.10; p < 0.00001). No other significant differences could be found. CONCLUSIONS Based on the available data, surgical treatment of primary patella dislocation significantly reduces the risk of patella redislocation.
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