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Kwak YH, Ko YJ, Kwon H, Koh YG, Aldosari AM, Nam JH, Kang KT. Application of a machine learning and optimization method to predict patellofemoral instability risk factors in children and adolescents. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39033342 DOI: 10.1002/ksa.12372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/03/2024] [Accepted: 07/08/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Conservative treatment remains the standard approach for first-time patellar dislocations. While risk factors for patellofemoral instability, a common paediatric injury, are well-established in adults, data concerning the progression of paediatric recurrent patellar dislocation remain scarce. A reproducible method was developed to quantitatively assess the patellofemoral morphology and anatomic risk factors in paediatric patients using magnetic resonance imaging (MRI) and machine learning analysis. METHODS Data were analyzed from a retrospective review (2005-2022) of paediatric patients diagnosed with acute lateral patellar dislocation (54 patients) who underwent MRI and were compared with an age-based control group (54 patients). Patellofemoral, tibial, tibiofemoral and patellar height parameters were measured. Differences between groups were analyzed with respect to MRI parameters. The potential diagnostic utility of the parameters was assessed via machine learning and genetic algorithm analyses. RESULTS Significant differences were observed between the two groups in six patellofemoral morphological parameters. Regarding patellar height morphological parameters, all methods exhibited significant between-group differences. Among the tibia and tibiofemoral morphological parameters, only the tibial tubercle-trochlear groove distance exhibited significant differences between the two groups. No sex-related differences were present. Significant variations were observed in patellar height parameters, particularly in the Koshino-Sugimoto (KS) index, which had the highest area under the curve (AUC: 0.87). Using genetic algorithms and logistic regression, our model excelled with seven key independent variables. CONCLUSION KS index and Wiberg index had the strongest association with lateral patellar dislocation. An optimized logistic regression model achieved an AUC of 0.934. Such performance is considered clinically relevant, indicating the model's effectiveness for the intended application. LEVEL OF EVIDENCE Level Ⅲ.
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Affiliation(s)
- Yoon Hae Kwak
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yu Jin Ko
- Cell & Developmental Biology, University of Rochester, Rochester, New York, USA
| | - Hyunjae Kwon
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yong-Gon Koh
- Department of Orthopaedic Surgery, Joint Reconstruction Center, Yonsei Sarang Hospital, Seoul, Korea
| | - Amaal M Aldosari
- Department of Orthopedic Surgery, Al Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Ji-Hoon Nam
- Department of Mechanical Engineering, Yonsei University, Seoul, Korea
- Skyve R&D LAB, Seoul, Korea
| | - Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, Seoul, Korea
- Skyve R&D LAB, Seoul, Korea
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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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Yu J, Li Y, Zhang K, Yang R, Yang X, Gong M, Long C, Fu W. The accuracy of multiple regression models for predicting the individual risk of recurrent lateral patellar dislocation. BMC Musculoskelet Disord 2023; 24:948. [PMID: 38057697 DOI: 10.1186/s12891-023-07094-2] [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] [Received: 09/20/2023] [Accepted: 12/04/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Recurrent lateral patellar dislocation (RLPD) poses a significant threat to patients' quality of life due to knee pain, patellofemoral cartilage damage, and potential traumatic arthritis. Predictive scoring systems have been developed to assess the risk of RLPD; however, their relative accuracy remains uncertain. PURPOSE To investigate the accuracy of the multiple regression models to predict the individual risk of recurrent LPD. METHODS The Patellar Instability probability calculator (PIP), Recurrent Instability of the Patella Score (RIP), and Patellar Instability Severity Score (PIS) scoring rules were measured in 171 patients with a history of patellar dislocation and 171 healthy individuals. Three prediction models were calculated based on the data to predict the risk of recurrent lateral patellar dislocation. The inter-observer and intra-observer reliability of each measurement parameter was evaluated. The predictive capacity of the three-prediction model was investigated using the receiver operating characteristic curve. RESULTS In the case group of 171 patients, PIS accurately predicted recurrent lateral Patella dislocation in 143 patients. RIP was 96, and PIP was 83. The positive predictive values were 92.9%, 64%, and 68% respectively. In the control group of 171 patients, the PIS was validated in 160 patients who would not experience dislocations. RIP was 117, and PIP was 50. The negative predictive values were 85.1%, 60.9%, and 36.2%, respectively. The area under the curve score for the PIS was 0.866, and the RIP was 0.673. the PIP was 0.678. CONCLUSION RIP and PIP did not work to predict LPD. PIS can accurately predict recurrent lateral patellar dislocation. It can aid doctors in making treatment decisions. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jiang Yu
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yijin Li
- Laboratory of Clinical Proteomics and Metabolomics, Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Kaibo Zhang
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Runze Yang
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaolong Yang
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Meng Gong
- Laboratory of Clinical Proteomics and Metabolomics, Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Long
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| | - Weili Fu
- Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
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Chen J, Li X, Feng Y, Li Q, Xu Z, Wang L, Zhang J, Quan Z, Zhou A. Lateral trochlear inclination measured by the transepicondylar axis holds potential for evaluating trochlear dysplasia in patients with lateral patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2023; 31:5611-5620. [PMID: 37851025 DOI: 10.1007/s00167-023-07614-6] [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: 01/10/2023] [Accepted: 09/29/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To verify that lateral trochlear inclination (LTI) measured by the transepicondylar axis can reliably be used to evaluate trochlear dysplasia (TD) on MRI and can serve as an objective indication of trochleoplasty for patients with lateral patellar dislocation (LPD). METHODS Eighty patients with recurrent LPD and eighty healthy subjects were included. TD, posterior condylar angle (PCA), and LTI measured by the posterior condylar reference line (LTIp), surgical transepicondylar axis (LTIs), and anatomical transepicondylar axis (LTIa) were assessed on MRI. The intraclass correlation coefficient (ICC) and Bland-Altman analysis were performed, the correlations and differences amongst the parameters were identified, and a binary logistic regression model was established. RESULTS Each measurement had excellent inter- and intra-observer agreement. The LTIp, LTIs and LTIa were smaller in the study group than in the control group, with mean differences of 9.0°, 7.2° and 7.0°, respectively (P < 0.001). The PCA was larger in patients with LPD than in the control group (P < 0.001). LTIp was associated with PCA in the study group (r = - 0.41, P < 0.001). The pathological values of LTIp, LTIs and LTIa were 11.7°, 15.3° and 17.4°, respectively. LTIs and LTIa were independent risk factors for LPD, with ORs of 7.33 (95% CI [1.06-52.90], P = 0.048) and 10.29 (95% CI [1.38-76.96], P = 0.023), respectively. CONCLUSION The LTI can be reliably measured by MRI, but LTIp could potentially decrease the recorded value from the actual inclination angle. LTIs and LTIa are more appropriate to serve as trochleoplasty indications for patients with LPD, which could help orthopedists with surgical decision-making. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jiaxing Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Xinyi Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yi Feng
- Medical Education Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qiaochu Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Zijie Xu
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, 100191, China
| | - Linbang Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
| | - Jian Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Zhengxue Quan
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China.
| | - Aiguo Zhou
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China.
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Danielsen O, Poulsen TA, Eysturoy NH, Mortensen ES, Hölmich P, Barfod KW. Trochlea dysplasia, increased TT-TG distance and patella alta are risk factors for developing first-time and recurrent patella dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:3806-3846. [PMID: 36854995 DOI: 10.1007/s00167-022-07255-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/23/2022] [Indexed: 03/02/2023]
Abstract
PURPOSE The aim of the study was to perform a systematic review and best knowledge synthesis of the present literature concerning biomechanical risk factors for developing first-time and recurrent patella dislocation. METHODS The study was performed as a systematic review following PRISMA guidelines. PubMed and EMBASE were systematically searched. Studies investigating participants with risk factors for first-time as well as recurrent patella dislocation were included. The records were screened, and data extracted independently by two researchers supervised by a third independent assessor. The study was registered in PROSPERO. RESULTS A total of 6233 records were screened, and 50 studies met the inclusion criteria. The biomechanical risk factors: trochlear dysplasia, increased tibial tuberosity-trochlear groove distance (TT-TG), and patella alta were found to be statistically significantly associated with patella dislocation in several publications and were thus recognized as risk factors for patella dislocation. The soft-tissue stabilizers: longer and thinner MPFL ligament, increased number of type 2C and decreased number of type 1 muscle fibers, and joint laxity were found to be statistically significantly associated with patella dislocation in a few publications, but due to limited evidence, no conclusion was made on this matter. CONCLUSION There is strong evidence in the literature that abnormalities of bony stabilizers, trochlear dysplasia, increased TT-TG distance, and patella alta are risk factors for patella dislocation. There is less evidence that soft-tissue stabilizers are risk factors. The study emphasizes the importance of a thorough investigation of bony stabilizers in clinical decision-making. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Oddrún Danielsen
- National Hospital of the Faroe Islands, J.C. Svabosgøta 41-49, 100, Tórshavn, Faroe Islands.
| | - Turið Akraberg Poulsen
- National Hospital of the Faroe Islands, J.C. Svabosgøta 41-49, 100, Tórshavn, Faroe Islands
| | | | | | - Per Hölmich
- Sports Orthopedic Research Center, Copenhagen, (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center, Copenhagen, (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
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Danielsen O, Poulsen TA, Eysturoy NH, Mortensen ES, Hölmich P, Barfod KW. Familial association and epidemilogical factors as risk factors for developing first time and recurrent patella dislocation: a systematic review and best knowledge synthesis of present literature. Knee Surg Sports Traumatol Arthrosc 2023; 31:3701-3733. [PMID: 36629887 DOI: 10.1007/s00167-022-07265-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/28/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE The aim of our study was to perform a systematic review and best knowledge synthesis of the present literature concerning the familial association and epidemiological factors as risk factors for developing first-time and recurrent patella dislocation. METHODS The study was conducted according to the PRISMA guidelines and registered in PROSPERO. EMBASE and PubMed were systematically searched on the 5th of May 2022. Studies investigating participants with genetic and epidemiological risk factors for the first time as well as recurrent patella dislocation were included. The records were screened, and data were extracted independently by two researchers supervised by a third independent assessor. RESULTS A total of 6,649 records were screened, and 67 studies were included. Familial association was described as a risk factor for patella dislocation in 17 studies. One study found that participants with a family history of patella dislocation had a 3.7 higher risk for patella dislocation in the contralateral asymptomatic knee, and another study found a family history of PD in 9% of 74 participants. Eleven studies found an accumulation of patella dislocation across generations in specific families. Additionally, a range of genetic syndromes was associated with patella dislocation. Young age is a well-investigated risk factor for patella dislocation, but the results are inconsistent. Only five and eight studies investigated skeletal immaturity and gender as risk factors for patella dislocation, respectively. CONCLUSION There may be a familial association with patella dislocation, but further investigation is necessary to determine the strength and etiology of the association. There is weak evidence that epidemiological risk factors, such as age, skeletal immaturity, gender, and BMI are risk factors for patella dislocation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Oddrún Danielsen
- National Hospital of the Faroe Islands, J.C. Svabosgøta 41-49, 100, Tórshavn, Faroe Islands.
| | - Turið Akraberg Poulsen
- National Hospital of the Faroe Islands, J.C. Svabosgøta 41-49, 100, Tórshavn, Faroe Islands
| | | | | | - Per Hölmich
- Sports Orthopedic Research Center-Copenhagen, (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen, (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
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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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Zhang W, Mou L, Zhang S, Liu W, Remila A, Han M, Xiang W, Fang R. 3D-printed individualized navigation template versus the fluoroscopic guide to defining the femoral tunnel for medial patellofemoral ligament reconstruction: A retrospective study. Medicine (Baltimore) 2023; 102:e32729. [PMID: 36705383 PMCID: PMC9876018 DOI: 10.1097/md.0000000000032729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
During medial patellofemoral ligament (MPFL) reconstruction, fluoroscopic determination of the femoral tunnel point is the most common method. However, there is a decrease in tunnel position accuracy due to rotation of the femur during fluoroscopy, as well as the damage to the operator from multiple fluoroscopies, whereas the 3D-printed individualized navigation template is not affected by this factor. This study focuses on the accuracy and early clinical efficacy of 2 different ways to determine the femoral tunnel (Schöttle point) for double-bundle isometric MPFL reconstruction. This is a retrospective study, conducted between 2016 and 2019, in which 60 patients with recurrent patellar dislocation were divided into 2 groups: 30 with MPFL reconstruction at the Schöttle point determined by 3D-printed individualized navigation template (group A) and 30 with MPFL reconstruction at the Schöttle point determined by fluoroscopic guidance (group B). The changes in patella congruence angle and patella tilt angle before and after surgery were assessed using computed tomography scans of the knee, knee function was assessed using the Kujala knee score and the international knee documentation committee (IKDC) score, and the 2 approaches were compared for the intraoperative establishment of the femoral tunnel position at a distance from Schöttle point. At a minimum of 3 years follow-up, patella tilt angle and patella congruence angle returned to normal levels and were statistically different from the preoperative range, with no significant differences between the 2 groups at the same period, and Kujala and IKDC scores of knee function were significantly improved in both groups after surgery. The mean Kujala and IKDC scores were statistically different between groups A and B at 3 and 6 months postoperatively. No statistically significant differences were seen between the 2 groups at the final follow-up. Both femoral tunnel localization approaches for double-bundle isometric MPFL reconstruction resulted in good knee function. At no < 3 years of follow-up, the use of a 3D-printed individualized navigation template did result in more accurate isometric points and higher knee function scores in the early postoperative period.
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Affiliation(s)
- Wenhao Zhang
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Limin Mou
- Emergency Trauma Surgery, Yichang Central Hospital, affiliated with Three Gorges University, Yicang, Hubei Province
| | - Shiping Zhang
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Wei Liu
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Aimaiti Remila
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Mingzhan Han
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Wenyuan Xiang
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Rui Fang
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
- * Correspondence: Rui Fang, Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province 830054, China (e-mail: )
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Chen J, Li Q, Liu S, Fan L, Yin B, Yang X, Wang L, Xu Z, Zhang J, Quan Z, Zhou A. Prediction of Subsequent Contralateral Patellar Dislocation after First-Time Dislocation Based on Patellofemoral Morphologies. J Clin Med 2022; 12:jcm12010180. [PMID: 36614981 PMCID: PMC9820933 DOI: 10.3390/jcm12010180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/03/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
The subsequent dislocation of a contralateral patellofemoral joint sometimes occurs after a first-time lateral patellar dislocation (LPD). However, the anatomic risk factors for subsequent contralateral LPD remain elusive. This study included 17 patients with contralateral LPD and 34 unilateral patellar dislocators. The anatomic parameters of the contralateral patellofemoral joints were measured using CT images and radiographs that were obtained at the time of the first dislocation. The Wilcoxon rank-sum test was performed, and a binary regression model was established to identify the risk factors. The receiver operating characteristic curves and the area under the curve (AUC) were analyzed. The tibial tubercle-Roman arch (TT-RA) distance was significantly different between patients with and without contralateral LPD (24.1 vs. 19.5 mm, p < 0.001). The hip−knee−ankle (HKA) angle, patellar tilt, congruence angle, and patellar displacement were greater in the study group than in the control group (p < 0.05). The TT-RA distance revealed an OR of 1.35 (95% CI (1.26−1.44]), p < 0.001) and an AUC of 0.727 for predicting contralateral LPD. The HKA angle revealed an OR of 1.74 (95% CI (1.51−2.00), p < 0.001) and an AUC of 0.797. The Patellar tilt, congruence angle, and patellar displacement had AUC values of 0.703, 0.725, and 0.817 for predicting contralateral LPD, respectively. In conclusion, the contralateral patellofemoral anatomic parameters were significantly different between patients with and without subsequent contralateral LPD. Increased TT-RA distance and excessive valgus deformity were risk factors and could serve as predictors for contralateral LPD. At first-time dislocation, the abnormal position of the patella relative to the trochlea may also be an important cause of subsequent LPD.
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Affiliation(s)
- Jiaxing Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Qiaochu Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Sizhu Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Lin Fan
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Baoshan Yin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Xinyu Yang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Linbang Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Zijie Xu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing 100191, China
| | - Jian Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Zhengxue Quan
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Z.Q.); (A.Z.)
| | - Aiguo Zhou
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Orthopedic Laboratory, Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Z.Q.); (A.Z.)
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10
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Femoral morphology affects postoperative alignment of the lower extremities in hybrid closed-wedge high tibial osteotomy. Arch Orthop Trauma Surg 2022; 142:3675-3685. [PMID: 34061210 DOI: 10.1007/s00402-021-03974-1] [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] [Received: 02/21/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study aimed to determine correction error predictors of lower extremitiy alignment after hybrid closed-wedge high tibial osteotomy (HCWHTO). MATERIALS AND METHODS From 2011 to 2015, 102 knees in 75 patients with medial compartment knee osteoarthritis of the knee and varus knee deformities who underwent HCWHTO were evaluated in this retrospective study with a minimum 2-year follow-up. Preoperative radiological parameters including weight-bearing line ratio (WBL ratio), mechanical leg axis angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and JLCA under varus or valgus stress were measured. The knees were divided into the following three groups based on the WBL ratio on average 54 months after procedure: acceptable (WBL crossing the tibial plateau between 50 and 70%), under-correction (< 50%), and overcorrection (> 70%). A multiple regression analysis was performed to evaluate predictors that could influence postoperative WBL ratio and cut-off values of predictive preoperative factors was analysed. RESULTS Significant differences in pre- and postoperative WBL ratios and mechanical leg axis angles were found. Preoperative mLDFA in the under-correction group (89.4° ± 2.1°) was significantly higher than that in the overcorrection group (87.4° ± 2.2°) (p = 0.015), while other preoperative parameters revealed no significant differences. The postoperative MPTA in the under-correction group (92.1° ± 3.7°) was significantly lower than that in the other two groups (p = 0.005 and p = 0.0001, respectively), while there was no significant change between the acceptable (94.6° ± 3.4°) and the overcorrection (96.7° ± 3.2°) groups. Multiple regression analysis revealed that mLDFA (β = - 0.316; p = 0.010) had a significant impact on postoperative WBLR. The cut-off value for under-correction of mLDFA was 89.5°and sensitivity and specificity were 53.6 and 71.6%, respectively (p = 0.014). CONCLUSIONS Preoperative mLDFA is significantly associated with postoperative alignment in HCWHTO. While postoperative MPTA is important, disregarding the preoperative mLDFA may bears a high risk of malcorrection. Varus alignment of the knee with larger mLDFA may be an indication for not only HCWHTO, but also for distal femoral osteotomy.
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11
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Change of the cross-sectional area of vastus medialis oblique in patients with recurrent patellar dislocation treated by tibial tubercle transfer combined with medial patellofemoral ligament reconstruction on axial CT. J Orthop Surg Res 2022; 17:469. [PMID: 36307822 PMCID: PMC9617303 DOI: 10.1186/s13018-022-03367-z] [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: 04/06/2022] [Accepted: 10/18/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To investigate the change of the cross-sectional area (CSA) of vastus medialis oblique (VMO) in patients with recurrent patellar dislocation (RPD) treated by tibial tubercle transfer combined with medial patellofemoral ligament (MPFL) reconstruction by imaging methods, and to guide clinical treatment and rehabilitation. METHODS From October 2015 to March 2022, 23 patients with RPD who underwent tibial tubercle transfer combined with MPFL reconstruction were retrospectively enrolled. All patients were assessed by CT in the supine position with the knee fully extended and the quadriceps relaxed. The CSA of VMO and the ratio of CSA of VMO to body weight (CSA/BW) were measured at the upper pole of the patella, 5 mm above the upper pole of the patella and 5 mm below the upper pole of patella. The differences of measured parameters were compared before surgery and at follow-up, including CSA of VMO and CSA/BW. Test level α = 0.05. RESULTS The tibial tubercle-trochlear groove (TT-TG) distance was significantly reduced at follow-up compared with that before surgery (27.91 ± 1.95 mm vs 12.33 ± 1.07 mm, P < 0.001). The CSA of VMO was significantly increased at follow-up compared with that before surgery at 5 mm below the upper pole of the patella (473.06 ± 106.32 mm2 vs 562.97 ± 157.90 mm2, P < 0.001), at the upper pole of the patella (641.23 ± 188.45 mm2 vs 700.23 ± 177.55 mm2, P = 0.029), and at 5 mm above the upper pole of the patella (788.25 ± 238.62 mm2 vs 849.79 ± 180.84 mm2, P = 0.018). The CSA/BW was significantly increased at follow-up compared with that before surgery at 5 mm below the upper pole of the patella (7.83 ± 2.52 mm2/kg vs 9.22 ± 3.54 mm2/kg, P < 0.001), at the upper pole of the patella (10.48 ± 3.62 mm2/kg vs 11.42 ± 4.14 mm2/kg, P = 0.020), and at 5 mm above the upper pole of the patella (12.86 ± 4.65 mm2/kg vs 13.68 ± 3.86 mm2/kg, P = 0.017). CONCLUSION After tibial tubercle transfer combined with MPFL reconstruction, CSA of VMO increased in patients with RPD, which will help to enhance patellar stability and reduce recurrence.
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12
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Xu Z, Song Y, Deng R, Zhang Z, Wang H, Yu JK. Pathological Thresholds of Segmental Femoral Torsion in Patients With Patellar Dislocation: Influence on Patellofemoral Malalignment. Orthop J Sports Med 2022; 10:23259671221125218. [PMID: 36329949 PMCID: PMC9623427 DOI: 10.1177/23259671221125218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/24/2022] [Indexed: 11/07/2022] Open
Abstract
Background Femoral torsion can be evaluated from different femoral segments. The
pathological thresholds for femoral torsion of different segments and the
influence of segmental femoral torsion on patellofemoral alignment remain
unknown. Purpose To compare femoral torsion between patients with recurrent patellar
dislocation and healthy individuals, to determine the statistical
physiological range and pathological thresholds of femoral torsion in
different segments, and to investigate the influence of femoral torsion on
patellofemoral malalignment. Study Design Cross-sectional study; Level of evidence, 3. Methods We retrospectively reviewed the records of patients with patellar dislocation
who received surgical treatment in our department between 2019 and 2020.
Healthy participants were recruited as the control group. The control
patients were asymptomatic and had no history of lower extremity disorders.
The differences in femoral torsion between the study and control groups were
compared. The diagnostic capacity of femoral torsion in different segments
and their correlation with patellar tilt were investigated. The mean value
and 95% CI of femoral torsion in different segments were established using
data from healthy volunteers. Results A total of 60 patients with patellar dislocation and 100 healthy volunteers
were included in this study. The total, mid, and distal femoral torsion
values differed significantly between the study and control groups
(P < .01). Total femoral torsion had the highest
diagnostic value (area under the receiver operating curve = 0.733). Total
torsion (r = 0.432; P < .001), mid
torsion (r = 0.242; P = .002), and distal
torsion (r = 0.324; P < .001) showed
significant correlations with patellar tilt. The pathological thresholds of
excessive femoral torsion of the total, proximal, mid, and distal femoral
segments were 24.73°, 46.68°, –6.55°, and 14.92°, respectively. Conclusion Patients with patellar dislocation had greater femoral torsion than healthy
individuals in multiple femoral segments. Excessive mid, distal, and total
torsion was associated with more significant patellar tilt.
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Affiliation(s)
- Zijie Xu
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China
| | - Yifan Song
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China
| | - Ronghui Deng
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China
| | - Zining Zhang
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China
| | - Haijun Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China.,Jia-Kuo Yu, MD, PhD, and Haijun Wang, MD, Sports Medicine
Department, Beijing Key Laboratory of Sports Injuries, Peking University Third
Hospital, Institute of Sports Medicine, Peking University, No. 49 North Garden
Road, Haidian District, Beijing 100191, China (
and ,
respectively)
| | - Jia-Kuo Yu
- Sports Medicine Department, Beijing Key Laboratory of Sports
Injuries, Peking University Third Hospital, Beijing, China.,Institute of Sports Medicine, Peking University, Beijing,
China.,Jia-Kuo Yu, MD, PhD, and Haijun Wang, MD, Sports Medicine
Department, Beijing Key Laboratory of Sports Injuries, Peking University Third
Hospital, Institute of Sports Medicine, Peking University, No. 49 North Garden
Road, Haidian District, Beijing 100191, China (
and ,
respectively)
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13
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Vivekanantha P, Kahlon H, Cohen D, de Sa D. Isolated medial patellofemoral ligament reconstruction results in similar postoperative outcomes as medial patellofemoral ligament reconstruction and tibial-tubercle osteotomy: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 31:2433-2445. [PMID: 36214831 DOI: 10.1007/s00167-022-07186-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine the effect of isolated medial patellofemoral ligament reconstruction (MPFLR) versus concomitant MPFLR and tibial-tubercle osteotomy (TTO) on patient-reported functional outcomes, rate of patellar redislocation, and rate of return to sport in skeletally mature patients with recurrent patellar instability and lateralization as defined by elevated tibial-tubercle trochlear groove (TT-TG) distance. METHODS Three databases MEDLINE, PubMed and EMBASE were searched from inception to July 10th, 2022 for literature outlining the management of patients with TT-TG indices greater than 15 mm with either isolated MPFLR or concomitant MPFLR and TTO procedures. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on functional outcomes via the Kujala anterior knee pain score, redislocation rates, return to sport rates, and complications were recorded. The MINORS score was used for all studies to perform a quality assessment of included studies. RESULTS A total of 31 studies comprising 1405 patients (1452 knees) were included in this review. The mean Kujala score in 13 studies comprising 848 total patients in the isolated MPFLR group was 85.0 (range 80.9-97.5) compared to a score of 83.7 (range 77.2-94.0) in 14 studies comprising 459 patients in the concomitant group. The mean pooled redislocation rate in 19 studies examining isolated MPFLR procedures comprising 948 patients was 3.1% (95% CI 2.1-4.4%, I2 = 7%) as opposed to 3.2% (95% CI 1.9-5.0%, I2 = 0%) in 15 studies comprising 486 patients in the concomitant group. The mean pooled return to sport rate in seven studies with 472 total patients in the isolated MPFLR group was 82% (95% CI 78-86%, I2 = 16%) compared to a score of 92% (95% CI 78-99%, I2 = 58%) in four studies comprising 54 patients in the concomitant group. There were similar complication rates between both treatment groups, including range of motion deficits, fractures, infections, and graft failures. CONCLUSION Isolated MPFLR leads to similar anterior knee pain, similar redislocation rates and lower return to sport rates than concomitant MPFLR and TTO procedures in patients with TT-TG distances greater than 15 mm. Information from this review can aid surgeons in their decision to choose MPFLR versus concomitant procedures for this patient population, and can also guide future studies on this topic. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Harjind Kahlon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada.
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Burger D, Feucht M, Muench LN, Forkel P, Imhoff AB, Mehl J. Good clinical outcomes after patellar cartilage repair with no evidence for inferior results in complex cases with the need for additional patellofemoral realignment procedures: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1752-1768. [PMID: 34510221 PMCID: PMC9033684 DOI: 10.1007/s00167-021-06728-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature analysed clinical results after regenerative cartilage repair of the patella with a special focus on the assessment and treatment of existing patellofemoral malalignment. METHODS A systematic review was conducted to identify articles reporting clinical results after cartilage regenerative surgeries of the patella using the PubMed and Scopus database. The extracted data included patient-reported outcome measures (PROMS) and whether cartilage repair was performed alone or in combination with concomitant surgeries of underlying patellofemoral co-pathologies. In cases of isolated cartilage repair, specific exclusion criteria regarding underlying co-pathologies were screened. In cases of concomitant surgeries, the type of surgeries and their specific indications were extracted. RESULTS A total of 35 original articles were included out of which 27 (77%) were cohort studies with level IV evidence. The most frequently used technique for cartilage restoration of the patella was autologous chondrocyte implantation (ACI). Results after isolated cartilage repair alone were reported by 15 (43%) studies. Of those studies, 9 (60%) excluded patients with underlying patellofemoral malalignment a priori and 6 (40%) did not analyse underlying co-pathologies at all. Among the studies including combined surgeries, the most frequently reported concomitant procedures were release of the lateral retinaculum, reconstruction of the medial patellofemoral ligament (MPFL), and osteotomy of the tibial tubercle. In summary, these studies showed lower preoperative PROMS but similar final PROMS in comparison with the studies reporting on isolated cartilage repair. The most frequently used PROMS were the IKDC-, Lysholm- and the Modified Cincinnati Score. CONCLUSION This comprehensive literature review demonstrated good clinical outcomes after patellar cartilage repair with no evidence of minor results even in complex cases with the need for additional patellofemoral realignment procedures. However, a meaningful statistical comparison between isolated patellar cartilage repair and combined co-procedures is not possible due to very heterogeneous patient cohorts and a lack of analysis of specific subgroups in recent literature. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Daniel Burger
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Matthias Feucht
- Department of Orthopaedic Surgery, Paulinenhilfe, Diakonieklinikum, Stuttgart, Germany
| | - Lukas N. Muench
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Philipp Forkel
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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