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Rosenthal RM, Froerer DL, Metz AK, Khalil AZ, Featherall J, Maak TG, Ernat JJ, Aoki SK. Physeal Location on the Distal Femoral Cortical Surface Is Consistently Proximal to Apparent Location on the Perfect Lateral Radiograph: A 3-Dimensional Digitally Reconstructed Radiograph Study. J Am Acad Orthop Surg 2024; 32:e826-e831. [PMID: 38773850 DOI: 10.5435/jaaos-d-23-00983] [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] [Received: 10/27/2023] [Accepted: 03/31/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION The perfect knee lateral radiograph visualizes anatomic landmarks on the distal femur for clinical and scientific purposes. However, radiographic imaging is a two-dimensional (2D) representation of a three-dimensional (3D) physis. The aim of this study was to characterize the perceived radiographic projection of the femoral physis using perfect lateral digitally reconstructed radiographs (DRRs) and to evaluate discrepancies from this projection to the physis at the lateral and medial cortices. METHODS Pediatric patients from a cohort of CT scans were analyzed. Inclusion criteria were an open physis; exclusion criteria were any implant or pathology affecting the physis. CT scans were imported into 3D imaging software and transformed into lateral DRRs and 3D renderings of the femur. The physis was divided into four equal segments, with fiducial markers placed at the "anterior," "midpoint," and "posterior" points. Lines extended from these points in the lateral and medial direction. The vertical distance from these lines, representing the radiographic projection of the physis, was measured relative to the physis at the lateral and medial cortex of the femur on coronal CT slices. RESULTS Thirty-one patients were included. On the perfect lateral radiograph DRR, the physis on the medial cortex was located proximal to the visualized physis by 6.64 ± 1.74 mm, 11.95 ± 1.67 mm, and 14.30 ± 1.75 mm at the anterior (25%), midpoint (50%), and posterior (75%) locations, respectively. On the lateral side, the physis on the lateral cortex was proximal to the visualized physis by 2.19 ± 1.13 mm, 3.71 ± 1.19 mm, and 6.74 ± 1.25 mm at the anterior, midpoint, and posterior locations, respectively. DISCUSSION In this cohort of pediatric patients, the location of the cortical physis was, in all areas measured, proximal to the projection of the visualized physis as seen on the perfect knee lateral DRR. The distance from radiographic physis to cortical physis was greater at the medial cortex compared with the lateral cortex. STUDY DESIGN Descriptive laboratory study. LEVEL OF EVIDENCE III, observational radiographic anatomic study.
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Affiliation(s)
- Reece M Rosenthal
- From the Department of Orthopaedics, University of Utah, Salt Lake City, UT (Rosenthal, Metz, Khalil, Featherall, Maak, Ernat, and Aoki), and the School of Medicine, University of Utah, Salt Lake City, Utah (Froerer)
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2
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Paschos NK. Arthroscopic Patella Realignment for Children And Adolescents: A Single Incision Technique. Arthrosc Tech 2024; 13:102900. [PMID: 38690340 PMCID: PMC11056612 DOI: 10.1016/j.eats.2023.102900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/01/2023] [Indexed: 05/02/2024] Open
Abstract
Management of patellofemoral conditions in children and adolescents can be extremely challenging. Apart from the patellofemoral instability patients, there are several other disorders that can cause significant morbidity, patellofemoral maltracking, patellar tilt, and Hoffa's fat pad impingement syndrome are common problems that may not respond to nonoperative management. Understanding the exact pathology and apply the appropriate management is critical for successful outcome. Identification of novel surgical interventions that can provide symptom relief in a safe manner is important. This technical note describes a surgical technique for patella realignment in young patients that combines safety, simplicity, and reproducibility.
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Affiliation(s)
- Nikolaos K. Paschos
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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Stavinoha TJ, Shea KG. Physeal Sparing Approaches for MPFL Reconstruction. Curr Rev Musculoskelet Med 2023; 16:598-606. [PMID: 38079082 PMCID: PMC10733270 DOI: 10.1007/s12178-023-09864-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW To update and concepts for pediatric physeal-sparing patellofemoral stabilization surgery. RECENT FINDINGS Recent studies have demonstrated positive results in patellofemoral stabilization in pediatric populations with physeal-sparing techniques that limit the potential for physeal damage. Comprehensive analysis remains limited by population and technique heterogeneity. Physeal-sparing patellofemoral stabilization, most significantly through physeal-sparing reconstruction of the medial patellofemoral ligament complex remains a viable option for pediatric patients with recurrent patellofemoral instability.
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Affiliation(s)
- Tyler J Stavinoha
- Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, TX, USA.
| | - Kevin G Shea
- Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, TX, USA
- Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
- Center for Academic Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Kirby JC, Brenner ME, Jones H, Wilson PL, Ellis HB. Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort. Am J Sports Med 2023; 51:656-662. [PMID: 36722715 DOI: 10.1177/03635465221147516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population. PURPOSE The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements. RESULTS The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161). CONCLUSION MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.
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Affiliation(s)
- Julia C Kirby
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | - Hunter Jones
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Accadbled F, Kerdoncuff A, Hidalgo Perea S, Green DW. Failure of isolated medial patellofemoral ligament reconstruction in children: Risk factors and management. J Child Orthop 2023; 17:34-39. [PMID: 36755558 PMCID: PMC9900016 DOI: 10.1177/18632521221149055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/14/2022] [Indexed: 01/15/2023] Open
Abstract
Background Patellofemoral instability is a frequent cause of referral in pediatric sports medicine. Isolated medial patellofemoral ligament reconstruction is widely used and provides satisfactory outcomes with a low failure rate. Given the success of this surgical technique, the literature on medial patellofemoral ligament reconstruction failures in the pediatric population is limited. Moreover, given the multifactorial nature of patellofemoral instability, the heterogeneity of the current literature, and the paucity of pediatric studies, medial patellofemoral ligament reconstruction failures are often difficult to analyze. Methods The purpose of this study was to retrospectively review the associated risk factors, surgical management, and the clinical outcomes at 2-year follow-up of skeletally immature patients that presented to our clinic with a failed medial patellofemoral ligament reconstruction. Results Of the 181 cases in 155 patients included in this study, treatment failed in 12 (7%). All 12 patients presented with at least one risk factor for patellofemoral instability, the most common being trochlear dysplasia and a high-grade J sign. Conclusions We conclude that isolated medial patellofemoral ligament reconstruction for patellofemoral instability in children has a low failure rate. Clinicians must assess pre-operative risk factors before surgical treatment is considered. A high-grade J sign and high-grade trochlear dysplasia were associated with medial patellofemoral ligament reconstruction failure in this cohort. Tailoring treatment to patients' associated risk factors selection may improve outcomes.
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Affiliation(s)
- Franck Accadbled
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Aude Kerdoncuff
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Sofia Hidalgo Perea
- Department of Pediatric Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Daniel W Green
- Department of Pediatric Orthopedics, Hospital for Special Surgery, New York, NY, USA
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Rueth MJ, Koehl P, Schuh A, Goyal T, Wagner D. Return to sports and short-term follow-up of 101 cases of medial patellofemoral ligament reconstruction using gracilis tendon autograft in children and adolescents. Arch Orthop Trauma Surg 2023; 143:447-452. [PMID: 35171327 DOI: 10.1007/s00402-022-04365-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/19/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION An acute patellofemoral dislocation is the most common acute knee injury in children. Recent studies suggest up to 40% of immature patients may develop recurrent instability. MPFL reconstruction has become a mainstay for the treatment of patellofemoral instability. Aim of the recent study is to show our experiences of MPFL reconstruction in patellar instability in immature patients using a gracilis autograft in respect to return to sport, growth plate disorders and short-term results. MATERIALS AND METHODS A total of 101 patients (50 females, 51 males) were included in this retrospective study. Mean age at time of operation was 14.8 ± 1.6 years. Primary outcome measures included patient satisfaction, Kujala score, recurrent instability, return to normal activity, return to sports, clinical leg axis and complications. Mann-Whitney U test was used for statistical analysis and alpha was set at p < 0.05 to declare significance. RESULTS At a mean follow-up of 32.0 ± 12.1 months 90/101 patients could be followed-up. 84% of all patients were satisfied or very satisfied with the result at latest follow-up. 86.6% of all patients were able to return to sports, 2.3% had a relevant deviation of the clinical leg axis, but symmetrical. In sum complication rate was 2.9%. Redislocation rate was 0.9% (1/101). Kujala Score improved significantly from 47.1 preoperatively to 85.3 postoperatively (p < 0.01). CONCLUSION Anatomic MPFL reconstruction using gracilis tendon allograft tissue is a safe procedure in children and adolescents with low risk of recurrent instability.
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Affiliation(s)
- Markus-Johannes Rueth
- Hospital of Trauma Surgery, Department of Sport Orthopedics and Reconstructive Surgery, Marktredwitz Hospital, 95615, Marktredwitz, Germany.
| | - Philipp Koehl
- Hospital of Trauma Surgery, Marktredwitz Hospital, 95615, Marktredwitz, Germany
| | - Alexander Schuh
- Hospital of Trauma Surgery, Department of Musculoskeletal Research, Marktredwitz Hospital, 95615, Marktredwitz, Germany
| | - Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Bathinda, Punjab, India
| | - Daniel Wagner
- Hessingpark-Clinic GmbH, Hessingstraße 17, 86199, Augsburg, Germany
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Migliorini F, Maffulli N, Bell A, Betsch M. Outcomes, Return to Sport, and Failures of MPFL Reconstruction Using Autografts in Children and Adolescents with Recurrent Patellofemoral Instability: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121892. [PMID: 36553335 PMCID: PMC9777394 DOI: 10.3390/children9121892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION This study systematically reviews and updates the current evidence on the outcomes of medial patellofemoral ligament (MPFL) reconstruction using autografts in children and adolescents with recurrent patellofemoral instability. The outcomes of interest were improvements in patient reported outcomes measures (PROMs), return to sport rates, and the rates of surgical failure. METHODS This systematic review was performed according to the 2020 PRISMA guidelines. The following electronic databases were accessed in October 2022: PubMed, Scopus, Web of Science. All the clinical studies which investigated the outcomes of MPFL reconstruction using autografts in children and adolescents with recurrent patellofemoral instability were accessed. Only studies which included patients younger than 18 years were considered. Techniques, case reports, guidelines, comments, editorials, letters, protocols, reviews, and meta-analyses were excluded. Studies which included patients with congenital or acute patellofemoral instability were not eligible, nor were those which focused exclusively on hyperlaxity. RESULTS Data from 477 patients (510 procedures) were retrieved. Of the patients, 41% (196 of 477) were women. The mean length of follow-up was 33.7 ± 28.8 months. The mean age of the patients was 14.6 ± 1.6 years. At the last follow-up, all PROMs of interest were statistically improved. The mean time to return to sport was 6.1 ± 1.1 months. Of the patients, 27% reduced their level of activity after surgical stabilization. A total of 87% of patients returned to practice sport. A total of 5% (26 of 477) and 2% (9 of 363) of patients experienced further dislocations and subluxations, respectively, during the follow-up period. Moreover, 4% (16 of 403) of patients underwent a further surgical procedure for patellofemoral instability within the follow-up period. CONCLUSION MPFL reconstruction using autografts is effective in children and adolescents with recurrent patellofemoral instability.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke on Trent ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London E1 4DG, UK
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
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Knapik DM, McCarthy CF, Drummond I, Liu RW, Gilmore A. Optimal Fluoroscopic Angulation to Determine Intercondylar Notch Violation during Pediatric Medial Patellofemoral Ligament Reconstruction. J Knee Surg 2022; 35:1440-1444. [PMID: 33636742 DOI: 10.1055/s-0041-1724131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Previous anatomic data has suggested that during pediatric medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel must be angled distally and anteriorly to avoid damage to the distal femoral physis and then intercondylar notch. The purpose of this study was to determine the optimal degree of fluoroscopic angulation necessary to radiographically determine the presence of intercondylar notch violation. Fourteen adult cadaveric human femora were disarticulated and under fluoroscopic guidance, Schöttle's point was identified. A 0.62-mm Kirschner wire was then drilled through the condyle to create minimal notch violation. The femur was then placed on a level radiolucent table and coronal plane radiographs angled from -15 to 60 degrees were obtained in 5-degree increments to determine the fluoroscopic angle at which intercondylar notch violation was most evident. Grading of optimal fluoroscopic angle between two authors found that violation of the notch was the best appreciated at a mean angle of 43 ± 15 degrees from neutral. Results from this study emphasize the importance of angling the beam to essentially obtain a notch view to assess for a breech.
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Affiliation(s)
- Derrick M Knapik
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Conor F McCarthy
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ian Drummond
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Raymond W Liu
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Allison Gilmore
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.,Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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Aitchison AH, Hidalgo Perea S, Schlichte LM, Green DW. Medial patellofemoral ligament reconstruction with simultaneous osteochondral fracture fixation is an effective treatment for adolescent patellar dislocation with osteochondral fractures. J Child Orthop 2022; 16:393-400. [PMID: 36238149 PMCID: PMC9551001 DOI: 10.1177/18632521221119541] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Osteochondral fractures can occur during patellar dislocation and often require treatment. The purpose of this study is to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction. METHODS A retrospective review of a cohort of 365 medial patellofemoral ligament reconstructions by a single surgeon from 2008 to 2019 was performed to identify patients who underwent simultaneous osteochondral fracture fixation with bioabsorbable nails. Demographic data, surgical details, clinical follow-up, and subsequent procedures were collected. RESULTS Forty medial patellofemoral ligament reconstructions with osteochondral fracture fixation were performed by a single surgeon from 2008 to 2019. The average age at surgery was 14.6 years (range 10.7-19.6 years). The average length of follow-up was 2.6 years (range 0.7-7.0 years). Eleven (28%) patients required a second surgery on the ipsilateral knee. One patient had recurrent instability and required revision medial patellofemoral ligament reconstruction and osteochondral allograft. The other 10 patients underwent a second surgery to address cartilage damage or debridement of nails. Of the four patients who required nail debridement, the average number of nails initially placed was 7 ± 1.7. This was significantly more than the patients who did not require second surgery related to nail debridement (4.1 ± 1.6, p < .05). CONCLUSION 28% of patients required a second procedure, most of which involved debridement of unhealed portions of the osteochondral fracture. At 2.6-year follow-up, only 2% of patients had a failure of their osteochondral fracture fixation requiring a cartilage restoration procedure. Osteochondral fracture fixation in adolescents with patellofemoral instability can be effectively treated with fixation and simultaneous medial patellofemoral ligament reconstruction. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
| | | | | | - Daniel W Green
- Daniel W Green, Division of Pediatric
Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New
York, NY 10021, USA.
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Medial Patellofemoral Ligament Reconstruction in the Pediatric Population: Skeletal Immaturity Does Not Affect Functional Outcomes but Demonstrates Increased Rate of Subsequent Knee Injury. Arthrosc Sports Med Rehabil 2022; 4:e1589-e1599. [PMID: 36312705 PMCID: PMC9596869 DOI: 10.1016/j.asmr.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 05/22/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To evaluate short- to mid-term-outcomes, including instability rates, following medial patellofemoral ligament (MPFL) reconstruction in skeletally immature versus mature pediatric patients. Methods Patients younger than age 18 with recurrent patellar instability who underwent primary allograft MPFL reconstruction by a single surgeon from 2013 to 2019 were identified. Skeletally immature patients underwent all-epiphyseal drilling and mature patients underwent metaphyseal drilling at the Schöttle’s point. Patients 1 year from surgery were contacted to complete questionnaires, which included the International Knee Documentation Committee score. Further data included chart and imaging review. Significance was determined by P < .05. Results Of 118 eligible patients, 88 completed questionnaires. There were 67 skeletally mature and 21 skeletally immature patients. The mature group was older (15 vs 13 years, P < .001), predominantly female (67 vs 43%, P = .046), and heavier (24.7 vs 18.9, P < .001). Trochlear dysplasia (P = .594), concomitant procedures (P = .336), graft choice (P = .274), and follow-up length (P = .107) did not differ, although mature patients more often underwent suture tape augmentation (68 vs 13%, P < .001). Immature patients had greater rates of ipsilateral injury (35 vs 16%, P = .043); redislocation rate did not differ (9 vs 3%, P = .225). Mature patients were more likely to respond “definitely yes or probably yes” when asked if they would undergo the same care if needed (96 vs 76%, P = .007). At minimum 2-year follow-up, subsequent ipsilateral injury rates did not differ, although willingness to undergo the same care remained significant (95 vs 69%, P = .010). In a multivariable elimination logistic regression model, skeletal maturity was the only variable associated with subsequent ipsilateral injury (P = .049). Conclusions Pediatric patients undergoing MPFL reconstruction have good and comparable outcomes regardless of skeletal maturity. However, younger age and lack of tape augmentation in skeletally immature patients may predispose them to subsequent injury. Level of Evidence III, case-control study.
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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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Xu J, Ye Z, Qiao Y, Xu C, Han K, Chen J, Dong S, Zhao J. Medial Patellofemoral Ligament Reconstruction Using Adductor-Transfer and Adductor-Sling at Nonanatomic Femoral Attachment Sites Leads to Unfavorable Graft-Length Change Patterns: A Descriptive Biomechanical Study. Arthroscopy 2022; 38:1557-1567. [PMID: 34767953 DOI: 10.1016/j.arthro.2021.10.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the graft length change patterns in nonanatomic adductor-transfer (AT) and adductor-sling (AS) medial patellofemoral ligament (MPFL) reconstruction with those in anatomic MPFL reconstruction (MPFLR) and to investigate the favorable isometric ranges (FIRs) of knee flexion. METHODS Eight small fresh-frozen cadaveric knees were mounted in a knee-customized jig with tensioned muscles to measure graft length changes from two patellar points to four femoral attachments using a linear variable displacement transducer. Femoral attachments were at the MPFL footprint center (MPFL-C) in anatomic MPFLR, adductor magnus (AM) footprint center (AM-C) in AT, and at 5-mm (AM-5) or 10-mm (AM-10) points proximal to AM-C in AS. The FIRs of these femoral attachments were determined after zeroing the graft length changes at different initial fixation angles. RESULTS Anatomic MPFL-C resulted in almost isometric graft length changes from 0° to 90°. At AM-C, the graft length changes displayed an increase from 0° to 45° and significantly greater length changes than those at MPFL-C from 60° to 90°. The graft length changes at both AM-5 and at AM-10 continuously increased with knee flexion angles and presented significantly larger graft length changes than those at MPFL-C and at AM-C from 30° to 90° and 60° to 90°, respectively. After zeroing graft length changes at different fixation angles, the FIRs of the MPFL-C covered all knee flexion angles, regardless of the patellar attachments and initial fixation angles. Moreover, with the smaller FIRs of AM-C observed at any fixation angle when compared with MPFL-C, fixing the graft at 0° to 30° in AT allowed the FIRs to cover the whole functional flexion range. However, the significantly larger graft length changes of both AM-5 and AM-10 resulted in extremely limited FIRs at any fixation angle. CONCLUSION Anatomic MPFL-C resulted in a favorable graft length change range (less than 2 mm) at 0° to 90° of knee flexion, which was close to the isometric graft behavior. However, nonanatomic attachments of AM-C in AT, and both AM-5 and AM-10 in AS caused significant anisometric graft length change patterns and limited FIRs. Moreover, AT had a smaller range of graft length change but wider FIRs compared to AS, indicating superior graft behavior for MPFLR. CLINICAL RELEVANCE Anatomic MPFLR is preferable for the treatment of in skeletally immature patients, followed in preference by nonanatomic AT. Nonanatomic AS should be performed cautiously.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Cregar WM, Huddleston HP, Shewman EF, Cole BJ, Yanke AB. Lateral Translation of the Patella in MPFC Reconstruction: A Biomechanical Study of Three Approaches. J Knee Surg 2022; 36:622-630. [PMID: 35144302 DOI: 10.1055/s-0041-1741549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to investigate whether differences exist in preventing lateral patellar translation between three distinct medial patellofemoral complex (MPFC) reconstruction procedures at varying knee flexion angles. Six cadaveric knee specimens were dissected, potted, and placed in a customized jig for testing. Lateral patellar displacement was measured at intervals between 0 and 90 degrees of knee flexion using a tensile testing machine with a 20 N lateral force applied to the patella. Each specimen was tested with the MPFC intact, sectioned, and after each of the three reconstruction techniques: MPFL, hybrid, and medial quadriceps-tendon femoral (MQTFL) reconstructions. There was significantly increased lateral patellar displacement following MPFC sectioning when compared with the intact state in early degrees of flexion (10-30 degrees) (p < 0.05). All three reconstruction groups restored patella stability and reduced lateral patellar displacement following sectioning from 0 to 30 degrees of flexion (p < 0.05). When compared with the intact group, all three reconstruction groups demonstrated reduced patella translation at full knee extension, while the MPFL and hybrid reconstruction groups additionally demonstrated significant reduction in patella translation at 10 degrees of flexion (p < 0.05). No significant differences were observed between the three reconstruction groups. This biomechanical study demonstrates the efficacy of three MPFC reconstruction techniques in patella stabilization following sectioning. Our results suggest that MPFL reconstruction may provide the most robust patella stabilization, whereas MQTFL reconstruction may be the most forgiving construct. This study suggests that MQTFL and hybrid reconstructions provide adequate resistance to lateral translation and may be used as an alternative to MPFL reconstruction.
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Affiliation(s)
- William M Cregar
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Hailey P Huddleston
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Elizabeth F Shewman
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brian J Cole
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Adam B Yanke
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
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Schlumberger M, Schuster P, Hofmann S, Mayer P, Immendörfer M, Mayr R, Richter J. Midterm Results After Isolated Medial Patellofemoral Ligament Reconstruction as First-Line Surgical Treatment in Skeletally Immature Patients Irrespective of Patellar Height and Trochlear Dysplasia. Am J Sports Med 2021; 49:3859-3866. [PMID: 34694139 DOI: 10.1177/03635465211050419] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament reconstruction in skeletally immature patients who experience lateral patellar dislocation has been reported to yield good results. Whether bony abnormalities such as patellar height and trochlear dysplasia should be addressed additionally is a topic of discussion. PURPOSE To evaluate patient-reported outcomes and redislocation rates after isolated medial patellofemoral ligament reconstruction as first-line surgical treatment for lateral patellar dislocation in skeletally immature patients. Further, to analyze epidemiological, intraoperative, and radiographical factors influencing redislocation and clinical outcome. STUDY DESIGN Case series; Level of evidence, 4. METHODS Prospectively collected data were retrospectively analyzed for adolescent patients younger than 16 years who underwent medial patellofemoral ligament reconstruction between 2014 and 2018. Inclusion criteria were isolated medial patellofemoral ligament reconstruction with gracilis tendon and availability of accurate pre- and postoperative radiographs with the presence of open physes. The patients were questioned regarding further surgery, redislocation, and clinical outcomes using the Tegner Activity Scale, International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm score, and Kujala score. The influence of diverse epidemiological, intraoperative, and radiographical parameters on the redislocation rates and clinical outcome was analyzed. RESULTS A total of 54 medial patellofemoral ligament reconstructions (49 patients) met the inclusion criteria. After 4.3 ± 1.7 years (range, 2.0-7.3 years), 45 reconstructions (83.3%) in 41 patients were available for follow-up. The distribution of trochlear dysplasia was as follows: type A and B, 19 cases (42.2%) each; type C, 6 cases (13.3%); and type D, 1 case (2.2%). Patellar redislocation occurred in 3 patients (6.7%). The mean Tegner, subjective IKDC, Lysholm, and Kujala scores at follow-up were 6.3 ± 1.6 (range, 3-9), 93.6 ± 8.8, 95.9 ± 7.4, and 97.9 ± 7.1, respectively. Patellar height and trochlear dysplasia had no influence on redislocation or clinical scores. The Lysholm score was lower in knees with intraoperative retropatellar chondral lesion grade ≥III versus grade <III (89.0 ± 19.2 vs 96.9 ± 3.6, respectively; P = .023); likewise, the Kujala score was lower in knees that were grade ≥III versus grade <III (90.0 ± 19.7 vs 98.1 ± 2.1, respectively; P = .015). CONCLUSION Isolated medial patellofemoral ligament reconstruction as first-line surgical treatment in skeletally immature patients yields excellent midterm results, irrespective of patellar height and trochlear dysplasia. Redislocation still occurs in a certain number of patients, and a higher degree of retropatellar chondral lesion is a predictor for a worse clinical outcome.
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Affiliation(s)
- Michael Schlumberger
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Schuster
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany.,Paracelsus Medical Private University, Clinic Nuremberg, Department of Orthopedics and Traumatology, Nuremberg, Germany
| | - Sophie Hofmann
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Mayer
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Micha Immendörfer
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Raul Mayr
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jörg Richter
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
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Tang J, Zhao J. Polyethylene Suture Augmentation of the Medial Patellofemoral Ligament in Skeletally Immature Patients with Recurrent Patella Dislocation. Arthrosc Tech 2021; 10:e2827-e2831. [PMID: 35004167 PMCID: PMC8719299 DOI: 10.1016/j.eats.2021.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/17/2021] [Indexed: 02/03/2023] Open
Abstract
In skeletally immature patients with recurrent patella dislocation that needs operation, how to increase the medial stability of the patella effectively without disturbance of the epiphysial plate is of concern. Through evaluation of multiple techniques that designed to avoid injury to the epiphysial plate, we found that medial patellofemoral ligament augmentation with high-strength nonabsorbable sutures is feasible and effective. Thus, we would like to describe this technique, whose critical point is the correct location and creation of the 2 femoral tunnels. We consider the introduction of the current technique will provide reasonable choices when operation is needed in this special group of patients.
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Affiliation(s)
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China,Address correspondence to Jinzhong Zhao, M.D., Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, 600 Yishan Rd., Shanghai 200233, China.
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Abstract
Through this article, the authors aim to summarize the techniques performed on both first time and recurrent skeletally immature patients experiencing patellar dislocation. This article focuses on several key points, such as the importance of medial patellofemoral ligament femoral insertions being distal to the growth plate and performing extensive lateral release and quadricep tendon lengthening in cases of obligatory dislocation. Although acknowledging the procedures discussed cannot be considered for all patients, as individuals with open growth plates may require additional operative time, in many cases these techniques yield high rates of success.
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D’Ambrosi R, Corona K, Capitani P, Coccioli G, Ursino N, Peretti GM. Complications and Recurrence of Patellar Instability after Medial Patellofemoral Ligament Reconstruction in Children and Adolescents: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:434. [PMID: 34064244 PMCID: PMC8224374 DOI: 10.3390/children8060434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to review the data available in the current literature concerning the complications and recurrence of instability following medial patellofemoral ligament (MPFL) reconstruction for patellar instability in young and adolescent patients (those <20 years old). METHODS A systematic review was performed based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, EMBASE, and Cochrane databases. The terms "medial patellofemoral ligament" or "MPFL" and "reconstruction" and "young" or "adolescents" or "children" were used. The inclusion criteria for the literature review comprised studies that reported the complications and recurrences of instability in patients who had undergone MPFL reconstruction for patellar instability. RESULTS In all, 332 patients were included in the review, of which 195 were females (63.5%) and 112 were males (36.5%), and they totaled 352 treated knees. The mean age at the time of the surgery was 14.28 years, and the mean follow-up duration was 30.17 months. A total of 16 (4.5%) complications were reported: one (0.3%) patella fracture, one (0.3%) screw removal due to intolerance, one (0.3%) infection, five (1.4%) wound complications, six (1.7%) subluxations and two (0.6%) instances of post-operative stiffness. A total of 18 (5.1%) recurrences of patellar instability were recorded. CONCLUSIONS MPFL reconstruction in young patients can be considered an effective and safe treatment leading to clinical improvement in terms of recurrence of dislocation. No major complications related to the technique were reported, but a high level of research evidence is required to better evaluate the clinical results in a long-term follow-up.
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Affiliation(s)
- Riccardo D’Ambrosi
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy; (G.C.); (N.U.); (G.M.P.)
| | - Katia Corona
- Dipartimento di Medicina e Scienze Della Salute Vincenzo Tiberio, Università degli Studi del Molise, 86100 Campobasso, Italy;
| | - Paolo Capitani
- A.S.S.T. Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Gianluca Coccioli
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy; (G.C.); (N.U.); (G.M.P.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy
| | - Nicola Ursino
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy; (G.C.); (N.U.); (G.M.P.)
| | - Giuseppe Maria Peretti
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy; (G.C.); (N.U.); (G.M.P.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy
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Black SR, Meyers KN, Nguyen JT, Green DW, Brady JM, Maher SA, Shubin Stein BE. Comparison of Ligament Isometry and Patellofemoral Contact Pressures for Medial Patellofemoral Ligament Reconstruction Techniques in Skeletally Immature Patients. Am J Sports Med 2020; 48:3557-3565. [PMID: 33135907 DOI: 10.1177/0363546520966609] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adult medial patellofemoral ligament (MPFL) reconstruction techniques are not appropriate for the skeletally immature patient given the proximity of the distal femoral physis. Biomechanical consequences of reconstructions aimed at avoiding the physis have not been adequately studied. PURPOSE To quantify the biomechanical effects of MPFL reconstruction techniques intended for skeletally immature patients. STUDY DESIGN Controlled laboratory study. METHODS Four MPFL reconstruction techniques were evaluated using a computationally augmented cadaveric model: (1) Schoettle point: adult-type reconstruction; (2) epiphyseal: socket distal to the femoral physis; (3) adductor sling: graft wrapped around the adductor tendon; (4) adductor transfer: adductor tendon transferred to patella. A custom testing frame was used to cycle 8 knees for each technique from 10° to 110° of flexion. Patellofemoral kinematics were recorded using a motion camera system, contact stresses were recorded using Tekscan pressure sensors, and MPFL length was computed using an inverse kinematics computational model. Change in MPFL length, patellar facet forces, and patellar kinematics were compared using generalized estimating equation modeling. RESULTS Schoettle point reconstruction was the most isometric, demonstrating isometry from 10° to 100°. The epiphyseal technique was isometric until 60°, after which the graft loosened with increasing flexion. The adductor sling and adductor transfer techniques were significantly more anisometric from 40° to 110°. Both grafts tightened with knee flexion and resulted in significantly more lateral patellar tilt versus the intact state in early flexion and significantly higher contact forces on the medial facet versus the epiphyseal technique in late flexion. CONCLUSION In this cadaveric simulation, the epiphyseal technique allowed for a more isometric ligament until midflexion, when the patella engaged within the trochlear groove. The adductor sling and adductor transfer grafts became tighter in flexion, resulting in potential loss of motion, pain, graft stretching, and failure. Marginal between-condition differences in patellofemoral contact mechanics and patellar kinematics were observed in late flexion. CLINICAL RELEVANCE In the skeletally immature patient, using an epiphyseal type MPFL reconstruction with the femoral attachment site distal to the physis results in a more isometric graft compared with techniques with attachment sites proximal to the physis.
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Affiliation(s)
| | | | | | - Daniel W Green
- Hospital for Special Surgery, New York City, New York, USA
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Medial Patellofemoral Ligament Reconstruction and Lateral Retinacular Lengthening in the Skeletally Immature Patient. Arthrosc Tech 2020; 9:e737-e745. [PMID: 32577346 PMCID: PMC7301218 DOI: 10.1016/j.eats.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/04/2020] [Indexed: 02/03/2023] Open
Abstract
Patellar instability remains a ubiquitous and troublesome problem in orthopaedics and represents a challenge in the pediatric population. Reconstruction of the medial patellofemoral ligament (MPFL) has become a mainstay of patellar instability management in recent years. As with any procedure at or around the physes, there is concern among surgeons regarding safe placement of hardware and drilled tunnels. The authors describe a technique for anatomic MPFL reconstruction with the aid of fluoroscopic guidance to maintain a "safe zone" without violating the distal femoral physis. This technique allows for reliable MPFL reconstruction in the skeletally immature population with concomitant lateral lengthening, while requiring only minor deviations from the procedure in a skeletally mature patient.
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Wilkens OE, Hannink G, van de Groes SAW. Recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. Knee Surg Sports Traumatol Arthrosc 2020; 28:1919-1931. [PMID: 31392368 PMCID: PMC7253385 DOI: 10.1007/s00167-019-05656-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/29/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Recurrent patellofemoral instability is a common knee injury in skeletally immature patients. Many surgical techniques have been described in the literature, all with different success rates. Purpose of this study was to perform a systematic review and meta-analysis of the available literature to assess recurrent patellofemoral instability rates after surgical treatment using MPFL reconstruction techniques and other soft tissue realignment techniques in skeletally immature patients. METHODS PubMed, Embase, Web of Science, and The Cochrane Library were searched to identify all original articles concerning the surgical treatment for patellofemoral instability in skeletally immature patients and that reported post-operative recurrent patellofemoral instability rates. Subsequently a risk of bias assessment was conducted and a meta-analysis was performed on reported post-operative recurrent patellofemoral instability rates after MPFL reconstruction techniques and other soft tissue realignment techniques. RESULTS Of the 21 eligible studies (448 knees in 389 patients), 10 studies reported on MPFL reconstruction techniques using different grafts and fixation techniques and 11 reported on other soft tissue realignment procedures. In total, 62 of the 448 (13.8%) treated knees showed recurrent patellofemoral instability during follow-up. The overall pooled recurrent patellofemoral instability rate was estimated to be 0.08 (95% CI 0.02-0.16). For MPFL reconstruction techniques, the pooled recurrent patellofemoral instability rate was estimated to be 0.02 (95% CI 0.00-0.09). For the other soft tissue realignment techniques, the pooled rate was estimated to be 0.15 (95% CI 0.04-0.31). No statistically significant difference in recurrent patellofemoral instability rates between MPFL reconstruction techniques and other soft tissue realignment techniques were found (n.s.). There was a large variation in treatment effects over different settings, including what effect is to be expected in future patients. CONCLUSION This systematic review and meta-analysis found that recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. The clinical relevance of this study is that it provides clinicians with the best currently available evidence on recurrent patellofemoral instability rates after surgical treatment for patellofemoral instability in skeletally immature patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Olivier E Wilkens
- Department of Orthopedics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Vellios EE, Trivellas M, Arshi A, Beck JJ. Recurrent Patellofemoral Instability in the Pediatric Patient: Management and Pitfalls. Curr Rev Musculoskelet Med 2020; 13:58-68. [PMID: 31983043 DOI: 10.1007/s12178-020-09607-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of the review is to discuss the relevant pathoanatomy, management, complications, and technical considerations for recurrent patellofemoral instability (PFI) in the pediatric population. Special consideration is given to recent literature and management of the patient with repeat instability following surgery. RECENT FINDINGS Patellar stabilization surgery is in principle dependent upon restoration of normal patellofemoral anatomy and dynamic alignment. Historically, treatment options have been numerous and include extensor mechanism realignment, trochleoplasty, and more recently repair and/or reconstruction of the medial patellofemoral ligament (MPFL) as a dynamic check rein during initial knee flexion. In skeletally immature patients, preference is given to physeal-sparing soft tissue procedures. While medial patellofemoral ligament reconstruction has become a popular option, postoperative failure is a persistent issue with rates ranging from 5 to 30% for PFI surgery in general without any single procedure (e.g., distal realignment, MPFL reconstruction) demonstrating clear superiority. Failure of surgical patellar stabilization is broadly believed to occur for three main reasons: (1) technical failure of the primary stabilization method, (2) unaddressed static and dynamic pathoanatomy during the primary stabilization, and (3) intrinsic risk factors (e.g., collagen disorders, ligamentous laxity). PFI is a common orthopedic condition affecting the pediatric and adolescent population. Treatment of repeat instability following surgery in the PFI patient requires understanding and addressing underlying pathoanatomic risk factors as well as risks and reasons for failure.
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Affiliation(s)
- Evan E Vellios
- Sports Medicine and Shoulder Service Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Myra Trivellas
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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