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Liu Z, Wu J, Gao X, Qin Z, Tian R, Wang C. Deep learning-based automatic measurement system for patellar height: a multicenter retrospective study. J Orthop Surg Res 2024; 19:324. [PMID: 38822361 PMCID: PMC11141039 DOI: 10.1186/s13018-024-04809-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/22/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The patellar height index is important; however, the measurement procedures are time-consuming and prone to significant variability among and within observers. We developed a deep learning-based automatic measurement system for the patellar height and evaluated its performance and generalization ability to accurately measure the patellar height index. METHODS We developed a dataset containing 3,923 lateral knee X-ray images. Notably, all X-ray images were from three tertiary level A hospitals, and 2,341 cases were included in the analysis after screening. By manually labeling key points, the model was trained using the residual network (ResNet) and high-resolution network (HRNet) for human pose estimation architectures to measure the patellar height index. Various data enhancement techniques were used to enhance the robustness of the model. The root mean square error (RMSE), object keypoint similarity (OKS), and percentage of correct keypoint (PCK) metrics were used to evaluate the training results. In addition, we used the intraclass correlation coefficient (ICC) to assess the consistency between manual and automatic measurements. RESULTS The HRNet model performed excellently in keypoint detection tasks by comparing different deep learning models. Furthermore, the pose_hrnet_w48 model was particularly outstanding in the RMSE, OKS, and PCK metrics, and the Insall-Salvati index (ISI) automatically calculated by this model was also highly consistent with the manual measurements (intraclass correlation coefficient [ICC], 0.809-0.885). This evidence demonstrates the accuracy and generalizability of this deep learning system in practical applications. CONCLUSION We successfully developed a deep learning-based automatic measurement system for the patellar height. The system demonstrated accuracy comparable to that of experienced radiologists and a strong generalizability across different datasets. It provides an essential tool for assessing and treating knee diseases early and monitoring and rehabilitation after knee surgery. Due to the potential bias in the selection of datasets in this study, different datasets should be examined in the future to optimize the model so that it can be reliably applied in clinical practice. TRIAL REGISTRATION The study was registered at the Medical Research Registration and Filing Information System (medicalresearch.org.cn) MR-61-23-013065. Date of registration: May 04, 2023 (retrospectively registered).
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Affiliation(s)
- Zeyu Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jiangjiang Wu
- College of Information and Communication Engineering, Harbin Engineering University, Heilongjiang, Harbin, China
| | - Xu Gao
- Department of Orthopedics, Xi'an Honghui Hospital, Xi'an, Shaanxi, China
| | - Zhipeng Qin
- Department of Orthopedics, The Second Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Run Tian
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Chunsheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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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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Roy KD, Joshi P, Ali I, Shenoy PM, Malek I, Barlow D, Syed A, Joshi Y. A comparative analysis of interobserver reliability and intraobserver reproducibility of the Oswestry-Bristol Classification and the Dejour Classification for trochlear dysplasia of the knee. Bone Jt Open 2023; 4:532-538. [PMID: 37470126 DOI: 10.1302/2633-1462.47.bjo-2023-0048] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Aims Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians' management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications. Methods In all, six assessors (four consultants and two registrars) independently evaluated 100 axial MRIs of the patellofemoral joint (PFJ) for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after four weeks. The inter- and intraobserver reliability scores were calculated using Cohen's kappa and Cronbach's α. Results Both classifications showed good to excellent interobserver reliability with high α scores. The OBC classification showed a substantial intraobserver agreement (mean kappa 0.628; p < 0.005) whereas the DJC showed a moderate agreement (mean kappa 0.572; p < 0.005). There was no significant difference in the kappa values when comparing the assessments by consultants with those by registrars, in either classification system. Conclusion This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on axial MRIs of the PFJ, with the simple-to-use OBC having a higher intraobserver reliability score than that of the DJC.
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Affiliation(s)
| | | | | | | | | | | | - Asad Syed
- Wrexham Maelor Hospital, Wrexham, UK
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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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Soft-tissue fixation is not inferior to suture-anchor fixation in reconstruction of the medial patellofemoral ligament using a nonresorbable suture tape. Knee Surg Sports Traumatol Arthrosc 2023; 31:292-298. [PMID: 35994076 DOI: 10.1007/s00167-022-07120-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Reconstruction of the medial patellofemoral ligament (MPFL-R) with nonresorbable suture tape (FiberTape®, FT) is becoming popular. Patella-side fixation of the FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate whether patella-side soft-tissue fixation can achieve equivalent primary stability compared to suture-anchor fixation. METHODS In ten human, fresh-frozen knee joint specimens (m/f 6/4; age 74 ± 9 a), the MPFL was identified and dissected near the femoral insertion site. In five knee joints, the MPFL-R using FT was performed with soft-tissue fixation at the patella (study group; SG), and in five knee joints, the FT was fixed via suture anchors (control group, CG). All reconstructions were evaluated until load to failure of the patella-side fixation with a displacement rate of 200 mm/min. RESULTS The mean maximum load to failure in the SG was 395.3 ± 57.9 N. All reconstructions failed by complete tearing off the medial patellar retinaculum from its medial patellar margin, but fixation of the FT remained stable. In the CG, the mean maximum load to failure was 239.4 ± 54.5 N and was significantly different compared to the SG (p = 0.04). All reconstructions failed via pullout of the suture anchors. Stiffness and elongation did not differ between the groups, and no failure of the FT was observed in any of the specimens. CONCLUSION Primary stability of soft-tissue MPFL-R using FT was superior to suture-anchor fixation. Both fixation techniques provided sufficient primary stability, superior to previously reported native MPFL tensile strengths. MPFL-R with FT could be a possible alternative procedure for MPFL-R, eliminating potential complications due to autologous tendon graft harvesting.
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Repo JP, Uimonen MM, Nevalainen MT, Nurmi H, Ponkilainen VT, Tuominen A, Paloneva J. Outcomes following the operative treatment of intra-articular fracture combined with medial patellofemoral ligament reconstruction after patellar dislocation. Knee Surg Relat Res 2022; 34:21. [PMID: 35418118 PMCID: PMC9008916 DOI: 10.1186/s43019-022-00150-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/03/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose We examine the outcomes following operative treatment of intra-articular fracture combined with medial patellofemoral ligament (MPFL) reconstruction after patella dislocation. Methods Patients were retrospectively identified from medical records using diagnostic and surgical procedure codes. Radiological anatomical parameters and bony abnormalities of injured knees were assessed from magnetic resonance images (MRI). Inclusion criteria were traumatic patellar dislocation with chondral or osteochondral fracture and MPFL rupture, operative treatment of a chondral or osteochondral fracture combined with MPFL reconstruction, and minimum follow-up of 2 years. Outcomes were measured using the Kujala score, Tegner activity scale, and the Knee injury and Osteoarthritis Outcome Score Quality-of-Life subscale (KOOS-QLS). Results During 2012 and 2015, 322 patients were treated because of patellar dislocation. Thirty-three patients had chondral or osteochondral fracture. Eleven patients (five males and six females) with a mean [standard deviation (SD)] age of 17.0 (6.5) years at the time of surgery met the inclusion criteria and were included. Five of the 11 patients had a subchondral and six an osteochondral fracture. Eight patients had a fracture in the patella and three in the femur. All patients had bony abnormalities in the knee. Nine out of 11 patients scored over 90/100 points on the Kujala scale and had good results on the Tegner scale [before surgery 5.0 (2.7) points versus after surgery 5.3 (1.6) points] and the KOOS-QLS [4.1 (4.2) points] outcome measures. Conclusion The removal or fixation of the fracture fragment combined with MPFL reconstruction is a feasible option in the treatment of symptomatic osteochondral or subchondral fragment in traumatic patellar dislocation. The short-term outcomes are encouraging. Level of evidence: Level IV, retrospective case series.
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Anatomic Risk Factors for Osteochondral Fracture of Acute First-Time Patellar Dislocation in Adolescents: A Retrospective Magnetic Resonance Imaging Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:6723326. [PMID: 35979012 PMCID: PMC9377871 DOI: 10.1155/2022/6723326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/21/2022] [Indexed: 11/30/2022]
Abstract
Objective To analyze the risk factors for osteochondral fracture (OCF) of first-time acute patellar dislocation (APD) through measurements of patellofemoral anatomy in adolescents. Methods In this prospective study, all patients were divided into two groups according to whether OCF was detected on magnetic resonance imaging (MRI): Group A (associated with OCF) and Group B (without OCF). Patellofemoral anatomy was evaluated with four aspects including trochlear/patellar dysplasia, patella location, patellofemoral matching, and morphologic classification. On MRI scans, trochlear facet asymmetry ratio (TFAR), lateral trochlear inclination (LTI), sulcus angle (SA), trochlear depth (TD), and patellar depth (PD) were measured to assess trochlear/patellar dysplasia. Insall–Salvati index (ISI), Caton–Deschamps index (CDI), Blackburne–Peel index (BPI), lateral patellofemoral angle (LPFA), patellar tilt angle (PTA), and lateral patellar displacement (LPD) were measured to show the location of patella. Patellofemoral matching was analyzed through the measurements of patellofemoral congruence angle (PFCA), patellofemoral index (PFI), and patellotrochlear index (PTI). Results A total of ninety-four adolescents from 49 boys and 45 girls (mean age, 15 years; range, 10–18 years) with first-time APD were recruited and included in Group A (65) and Group B (29). The PFI (2.62 ± 0.51 vs. 2.10 ± 0.44) and PTI (0.28 ± 0.05 vs. 0.22 ± 0.07) were significantly higher in Group B than Group A (P < 0.05). There were no significant differences in other quantitative outcomes of the two groups (P > 0.05). The distribution of Dejour/Wiberg classification was statistically similar between the two groups (P > 0.05). Conclusions Adolescent patients with first-time APD complicating OCF have closer morphologic features of patellofemoral dysplasia and patella location when compared to adolescents without OCF. Abnormal patellofemoral matching increases the risk of OCF after first-time APD in adolescents.
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Migliorini F, Pilone M, Eschweiler J, Marsilio E, Hildebrand F, Maffulli N. High Rates of Damage to the Medial Patellofemoral Ligament, Lateral Trochlea, and Patellar Crest After Acute Patellar Dislocation: Magnetic Resonance Imaging Analysis. Arthroscopy 2022; 38:2472-2479. [PMID: 35157964 DOI: 10.1016/j.arthro.2022.01.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary outcome of interest of this study was to determine the frequency, location, and extent of chondral injuries and medial patellofemoral ligament (MPFL) tears, along with the rate of loose bodies, in the knee after acute primary patellar dislocation. The secondary outcome of interest was to conduct a multivariate analysis to investigate whether the presence of pathoanatomic abnormalities, including structural differences in the knees of the patients, is associated with the features of the lesions. METHODS Patients who underwent magnetic resonance imaging after primary acute patellar dislocation were identified from our institutional databases. We analyzed a total of 175 magnetic resonance imaging scans of patients aged between 14 and 25 years who were eligible for inclusion. RESULTS Chondral damage to the medial facet of the patella was present in 36 patients; patellar crest, 78 patients; and lateral patellar facet, 28 patients. One patient presented with chondral defects in the medial trochlear facet, whereas 118 patients showed chondral defects in the lateral trochlear facet. Loose bodies were present in 142 patients. A total of 161 patients (92%) showed MPFL damage. The patellar portion was affected in 119 patients. Of the patients, 28 showed a partially damaged MPFL (<50%), 42 showed MPFL damage greater than 50%, and 49 presented with a complete tear of the MPFL. MPFL lesions were observed on the femoral side in 42 patients. Fourteen patients presented with an avulsion fracture on the patellar side; 28 patients, on the femoral side. CONCLUSIONS The MPFL was injured in 92% of 175 patients after a first-time acute patellar dislocation. Chondral damage was most frequent at the patellar crest, followed by the lateral femoral epicondyle. No association was found between patella alta, the sulcus angle, the Q angle, the tibial tubercle-trochlear groove distance, trochlear and patellar dysplasia, and soft-tissue damage. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marco Pilone
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Jörg Eschweiler
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Emanuela Marsilio
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy; Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, England; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, England
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MRI as the optimal imaging modality for assessment and management of osteochondral fractures and loose bodies following traumatic patellar dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 31:1744-1752. [PMID: 35796753 DOI: 10.1007/s00167-022-07043-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/09/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To assess the imaging modalities used for diagnosis, as well as the management decisions of patients with osteochondral fractures (OCF) and loose bodies following traumatic patellar dislocation. METHODS According to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA), MEDLINE, EMBASE, Web of Science, and PubMed were searched for results from January 1, 2000, to May 18, 2021, in two subsequent searches for English language studies that presented data on traumatic patellar dislocation. Quality of selected papers was assessed using the Methodological Index for Non-Randomised Studies (MINORS) and the Risk of Bias (RoB) 2.0 protocol. Results were qualitatively synthesised, and descriptive statistics were calculated. RESULTS Forty studies totalling 3074 patients (1407 females) were included for the analysis. The mean age was 18.9 years (range 0-69). The population included 2446 first-time dislocations. The imaging modalities used were: 71.1% MRI, 52.6% plain radiography, 12.1% CT, and 0.68% ultrasound. In the 25 studies that reported the number of OCF, a total of 38.3% of patients were found to have OCF. 43.3% of patients with a first-time dislocation, and 34.7% of patients with previous dislocations, had at least one OCF. In the included paediatric studies (maximum age ≤ 18), the presence of OCF was detected by plain radiography in 10.1% of patients, MRI in 76.6% of patients, and CT in 89.5% of patients. For management of an OCF, the surgical options include fixation for larger pieces, excision for smaller pieces, and conservative management on a case-by-case basis. CONCLUSIONS Based on the current available evidence, assessment and management of patellar dislocations and subsequent OCFs vary, with radiography and MRI as the main imaging modalities on presentation and particular benefit for MRI in the paediatric population. Findings from this study suggest the highest rate of OCF detection with MRI, and thus, surgeons should consider routinely ordering an MRI in patients with first-time patellar dislocation. Regarding management of OCFs, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. Few studies choose conservative management of OCFs due to later requirements for surgical management. Future work should focus on large, high-quality studies, and implementation of randomised control trials to form guidelines for imaging patellar dislocations and management of OCFs. LEVEL OF EVIDENCE Level IV.
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Zheng L, Si XL, Zhang M, Zhang GY. Factors associated with acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time lateral patellar dislocation: A prospective magnetic resonance imaging study. Injury 2022; 53:2644-2649. [PMID: 35613966 DOI: 10.1016/j.injury.2022.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify risk factors of acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time lateral patellar dislocation (LPD). METHODS Magnetic resonance images were prospectively analyzed in 115 patients in an acute first-time LPD. Factors included gender, skeletal maturity, trochlear dysplasia, patellar height, and tibial tuberosity-trochlear groove (TT-TG) distance. Binary logistic regression analysis was carried out to identify the independent risk factors for the incidence of acute articular cartilage lesions of the patella and lateral femoral condyle in acute first-time LPD. RESULTS The incidence of acute articular cartilage lesion of the patella and lateral femoral condyle were 46.1% and 27% in acute first-time LPD, respectively. Univariate analysis revealed significantly higher incidence rate of acute articular cartilage lesion of the patella in male (P = 0.027), skeletally mature (P = 0.035), normal TT-TG distance (P = 0.043) and normal femoral trochlea (P = 0.031). Risk factors for the incidence of acute articular cartilage lesion of the patella were skeletally mature (odds ratio (OR): 2.324), normal TT-TG distance (OR: 2.824) and normal femoral trochlea (OR: 3.835). Univariate analysis revealed significantly higher incidence rate of acute articular cartilage lesion of the lateral femoral condyle in skeletally mature (P = 0.027) and normal femoral trochlea (P = 0.031). Risk factor for the incidence of acute articular cartilage lesion of the lateral femoral condyle was normal femoral trochlea (OR: 3.347). CONCLUSIONS For patients in acute first-time LPD, compared with other parameters, the normal femoral trochlea, normal TT-TG distance and skeletally mature are independent risk factors for the incidence of acute articular cartilage lesion of the patella, and the normal femoral trochlea is an independent risk factor for the incidence of acute articular cartilage lesion of the lateral femoral condyle.
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Affiliation(s)
- Lei Zheng
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Forces, Jinan 250014, China
| | - Xiao-Lin Si
- Shandong First Medical University, Jinan 250014, China; Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated With Shandong First Medical University, Jinan 250014, China
| | - Meng Zhang
- Shandong First Medical University, Jinan 250014, China; Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated With Shandong First Medical University, Jinan 250014, China
| | - Guang-Ying Zhang
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated With Shandong First Medical University, Jinan 250014, China.
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Knapik DM, Kunze KN, Azua E, Vadhera A, Yanke AB, Chahla J. Radiographic and Clinical Outcomes After Tibial Tubercle Osteotomy for the Treatment of Patella Alta: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:2042-2051. [PMID: 34038256 DOI: 10.1177/03635465211012371] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue-based stabilization. PURPOSE To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations. RESULTS Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%). CONCLUSION TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.
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Affiliation(s)
| | - Kyle N Kunze
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA.,Rush University School of Medicine, Chicago, Illinois, USA
| | - Eric Azua
- Rush University School of Medicine, Chicago, Illinois, USA
| | - Amar Vadhera
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA.,Rush University School of Medicine, Chicago, Illinois, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA.,Rush University School of Medicine, Chicago, Illinois, USA
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12
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The Tibial Tubercle-Trochlear Groove Distance/Trochlear Dysplasia Index Quotient Is the Most Accurate Indicator for Determining Patellofemoral Instability Risk. Arthroscopy 2022; 38:1608-1614. [PMID: 34450216 DOI: 10.1016/j.arthro.2021.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary aim of our study was to evaluate diagnostic accuracy of the tibial tubercle-trochlear groove (TT-TG) distance relative to associated quotients produced from trochlear width (TT-TG distance/TW) and trochlear dysplasia index (TT-TG distance/TDI) for detecting patellofemoral instability. Secondary aims included identifying thresholds for risk and comparing differences between cases and controls. METHODS Consecutive sampling of electronic medical records produced 48 (21 males, 27 females) patellofemoral instability cases (19 ± 7 years old) and 79 (61 males, 18 females) controls (23 ± 4 years old) who had a history of isolated meniscal lesion, as evaluated by magnetic resonance imaging. Standardized methods were employed with measurements executed in a blinded and randomized manner. A receiver operating characteristic curve assessed accuracy by area under the curve (AUC). The index of union (IU) was employed to identify a threshold for risk. Two-sample t-tests examined group differences. P < .05 denoted statistical significance. RESULTS The AUC values were .69 (.60, .79) for TT-TG distance, .81 (.73, .88) for TT-TG distance/TW, and .85 (.78, .91) for TT-TG distance/TDI. Thresholds were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. Cases demonstrated statistically significant (P < .001) greater values for each measure compared with controls: TT-TG distance (15.8 ± 4.2 mm vs 12.9 ± 3.6 mm, [1.4, 4.3]); TT-TG distance/TW (.51 ± .24 vs .31 ± .09, [.13, .27]); TT-TG distance/TDI (3.07 ± 1.55 vs 1.7 ± .7, [.9, 1.84]). CONCLUSION The TT-TG distance, TT-TG distance/TW, and TT-TG distance/TDI measures were 69%, 81%, and 85%, respectively, accurate for determining patellofemoral instability risk. Thresholds for risk were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. The thresholds reported in this study may help in advancing clinical decision-making. LEVEL OF EVIDENCE Level III, diagnostic retrospective comparative observatory trial.
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Dynamic Mediolateral Patellar Translation Is a Sex- and Size-Independent Parameter of Adult Proximal Patellar Tracking Using Dynamic 3 Tesla Magnetic Resonance Imaging. Arthroscopy 2022; 38:1571-1580. [PMID: 34715275 DOI: 10.1016/j.arthro.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide normal values for physiological patellofemoral tracking in a representative group of healthy individuals, as well as sex differences, using real-time 3T-magnetic resonance imaging (MRI) and to test for the reliability of the presented technique. METHODS One hundred knees of healthy individuals with no history of patellofemoral symptoms were scanned with dynamic MRI sequences, during repetitive cycles of flexion (40°) and full extension. Within a 30-seconds time-frame, three simultaneous, transverse slices were acquired. Dynamic mediolateral patellar translation (dMPT) and dynamic patellar tilt (dPT) were measured on two occasions by two independent examiners. Common radiological parameters were measured using static MRI, and correlations were calculated. RESULTS 100 knees (53 right, 47 left; age: 26.7 ± 4.4 years; BMI: 22.5 ± 3.1) of 57 individuals (27 females, 30 males) were included. Mean height was 170.1 ± 7.7 cm in women and 181.8 ± 6.4 cm in men. Average patella diameter was 37.9 ± 2.7 (95% CI 37.1-38.7) mm in women and 42.4 ± 3.2 (95% CI 41.5-43.3) mm in men. In females, the patellar diameters and intercondylar distances were significantly smaller than in males (P < .001). Radiological parameters for patellar maltracking were within the normal range. During the range of motion, mean dMPT was 1.7 ± 2.4 (95% CI .9-2.5) mm in females and 1.8 ± 2.7 (95% CI 1.1-2.6) mm in males (P = .766). Mean dPT was 1.3 ± 2.9° (95% CI .4-2.1°) in females and -0.2 ± 3.8° (95% CI -1.2-.9°) in males (P = .036). Neither dMPT nor dPT was correlated with height, BMI, or patellar diameter. Intercondylar distance correlated weakly with dPT (r = -.241; P = .041). Intra- and interrater reliability were excellent for dMPT and dPT. CONCLUSION Dynamic mediolateral patellar translation is a size- and sex-independent parameter for proximal patellar tracking. In healthy individuals without patellofemoral abnormalities normal dMPT proximal to the trochlea groove was 1.7 ± 2.5 (1.2-2.2) mm, independent of size or sex. Normal dPT showed a dependency on sex and was 1.3 ± 2.9 (.4-2.1)° in women and -0.2 ± 3.8 (-1.2-0.9)° in men. LEVEL OF EVIDENCE Level II, diagnostic study.
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14
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Ormeci T, Turkten I, Sakul BU. Radiological evaluation of patellofemoral instability and possible causes of assessment errors. World J Methodol 2022; 12:64-82. [PMID: 35433342 PMCID: PMC8984217 DOI: 10.5662/wjm.v12.i2.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 10/27/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
Patellofemoral instability (PI) is the disruption of the patella’s relationship with the trochlear groove as a result of abnormal movement of the patella. To identify the presence of PI, conventional radiographs (anteroposterior, lateral, and axial or skyline views), magnetic resonance imaging, and computed tomography are used. In this study, we examined four main instability factors: Trochlear dysplasia, patella alta, tibial tuberosity–trochlear groove distance, and patellar tilt. We also briefly review some of the other assessment methods used in the quantitative and qualitative assessment of the patellofemoral joint, such as patellar size and shape, lateral trochlear inclination, trochlear depth, trochlear angle, and sulcus angle, in cases of PI. In addition, we reviewed the evaluation of coronal alignment, femoral anteversion, and tibial torsion. Possible causes of error that can be made when evaluating these factors are examined. PI is a multi-factorial problem. Many problems affecting bone structure and muscles morphologically and functionally can cause this condition. It is necessary to understand normal anatomy and biomechanics to make more accurate radiological measurements and to identify causes. Knowing the possible causes of measurement errors that may occur during radiological measurements and avoiding these pitfalls can provide a more reliable road map for treatment. This determines whether the disease will be treated medically and with rehabilitation or surgery without causing further complications.
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Affiliation(s)
- Tugrul Ormeci
- Department of Radiology, School of Medicine, İstanbul Medipol University, Istanbul 34200, Turkey
| | - Ismail Turkten
- Department of Anatomy, School of Medicine, İstanbul Medipol University, Istanbul 34820, Beykoz, Turkey
| | - Bayram Ufuk Sakul
- Department of Anatomy, School of Medicine, İstanbul Medipol University, Istanbul 34820, Beykoz, Turkey
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15
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Das P, Karmakar A. Medial patellofemoral ligament reconstruction: An uncommon solution for a common problem. Int J Appl Basic Med Res 2022; 12:144-147. [PMID: 35754665 PMCID: PMC9215180 DOI: 10.4103/ijabmr.ijabmr_445_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 11/23/2022] Open
Abstract
Patellofemoral dislocations are commonly encountered knee ailment. Although majority of the patients are managed conservatively, depending on the patients’ demands and predisposing factors, patients with recurrent dislocations often require surgical intervention. The main aim of any surgical procedure should be to restore the anatomy of the soft tissue as well as the bony elements. We here describe a technique which combines transverse patella double tunnel technique with tibial tuberosity distalization and medicalization to reconstruct the medial patellofemoral ligament using a free autologous semitendinosus graft.
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16
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Fuchs A, Feucht MJ, Dickschas J, Frings J, Siegel M, Yilmaz T, Schmal H, Izadpanah K. Interobserver reliability is higher for assessments with 3D software-generated models than with conventional MRI images in the classification of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 2022; 30:1654-1660. [PMID: 34423397 PMCID: PMC9033701 DOI: 10.1007/s00167-021-06697-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/10/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour. METHODS Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour's 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen's kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement. RESULTS The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented. CONCLUSION Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Andreas Fuchs
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
| | - Matthias J. Feucht
- Orthopädische Klinik Paulinenhilfe, Diakonieklinikum Stuttgart, Rosenbergstr. 38, 70176 Stuttgart, Germany
| | - Jörg Dickschas
- grid.7708.80000 0000 9428 7911Klinik Für Orthopädie Und Unfallchirurgie, Klinikum Bamberg, Buger Strasse 80, 96049 Bamberg, Germany
| | - Jannik Frings
- grid.13648.380000 0001 2180 3484Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Markus Siegel
- grid.7708.80000 0000 9428 7911Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Tayfun Yilmaz
- grid.7708.80000 0000 9428 7911Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Hagen Schmal
- grid.7708.80000 0000 9428 7911Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Kaywan Izadpanah
- grid.7708.80000 0000 9428 7911Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Albert Ludwigs University Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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Palmowski Y, Jung T, Doering AK, Gwinner C, Schatka I, Bartek B. Analysis of cartilage injury patterns and risk factors for knee joint damage in patients with primary lateral patella dislocations. PLoS One 2021; 16:e0258240. [PMID: 34648534 PMCID: PMC8516305 DOI: 10.1371/journal.pone.0258240] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Lateral patellar dislocation (LPD) frequently causes damage to the knee. Injury patterns and risk factors contributing to such injuries have not yet been examined in detail. METHODS We retrospectively analyzed 50 consecutive patients with primary LPD. Two reviewers evaluated the MRI images regarding risk factors for LPD (Dejours classification; Caton-Deschamps Index, CDI; distance from the tibial tuberosity to trochlear groove, TT-TG; trochlear depth, TD) as well as joint damages according to the Whole-Organ Magnetic Resonance Imaging Score (WORMS). RESULTS 33 male and 17 female patients with a mean age of 23.2 (±9.6) years were included in this study. 52% were classified Dejours ≥ B, 34% had a CDI ≥ 1.3, 22% a TT-TG ≥ 20mm and 52% a TD < 3mm. 49 out of 50 patients (98%) showed abnormalities according to WORMS. The most frequently observed abnormalities were synovitis/effusion (49/50, 98%), bone marrow oedema (44/50, 88%) and cartilage damage (42/50, 84%). Most frequently affected subregions were medial (41/50, 82%) and lateral (31/50, 62%) patella as well as the anterior (43/50, 86%), central (42/50, 84%) and posterior (11/50, 22%) portion of the lateral femoral condyle. There was no significant correlation between any of the examined risk factors and joint damages according to WORMS. Male patients had higher scores regarding total cartilage damage (5.11 vs. 2.56, p = 0.029), total score for the lateral femorotibial joint (3.15 vs. 1.65, p = 0.026) and overall total WORMS score (12.15 vs. 8.29, p = 0.038). CONCLUSION Risk factors for LPD do not influence the risk of damages to the knee joint after primary LPD. Although LPD is generally known to affect more female than male patients, male patients suffered more severe injuries after primary LPD, particularly of the lateral femorotibial joint. Overall, our results underline the importance of MRI imaging after primary LPD.
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Affiliation(s)
- Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anne-Katrin Doering
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Imke Schatka
- Center for Diagnostic and Interventional Radiology and Nuclear Medicine, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Bartek
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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18
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Milinkovic DD, Fink C, Kittl C, Sillanpää P, Herbst E, Raschke MJ, Herbort M. Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study. Am J Sports Med 2021; 49:1827-1838. [PMID: 33960859 DOI: 10.1177/03635465211009540] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. PURPOSE To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft's application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. RESULTS The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. CONCLUSION The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. CLINICAL RELEVANCE Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.
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Affiliation(s)
| | - Christian Fink
- Gelenkpunk-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Petri Sillanpää
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Pihlajalinna Koskisairaala Hospital, Tampere, Finland
| | | | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,OCM Orthopedic Surgery Munich Clinic, Munich, Germany
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19
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Zheng L, Ding HY, Feng Y, Sun BS, Zhu LL, Zhang GY. Gender-related differences in concomitant articular injuries after acute lateral patellar dislocation. Injury 2021; 52:1549-1555. [PMID: 33097203 DOI: 10.1016/j.injury.2020.10.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the gender differences in the concomitant articular injuries after acute lateral patellar dislocation (LPD). METHODS Magnetic resonance images were prospectively analyzed in 166 patients after an acute LPD. Concomitant articular injuries included bone contusion, medial patellofemoral ligament (MPFL) injury, articular cartilage lesion, and vastus medialis obliquus (VMO) lesion. Statistical analyses were performed between the patient's gender and the incidence of concomitant articular injuries in adolescent and adult subgroups. RESULTS The incidence of partial and complete MPFL tear in adolescent males and females were (45%, 50%) and (63.2%, 29.8%), respectively. Compared with adolescent females, adolescent males showed higher incidence of complete MPFL tear (P = 0.049). The incidence of articular cartilage lesion of patella in adolescent males and females were 40% and 21.1%, respectively. Compared with adolescent females, adolescent males showed higher incidence of articular cartilage lesion of the patella (P = 0.043). No correlations were identified in other injuries in the adolescent group. The incidence of partial and complete MPFL tear in adult males and females were (34.4%, 65.6%) and (56.8%, 37.8%), respectively. Compared with adult females, adult males showed higher incidence of complete MPFL tear (P = 0.036). The incidence of articular cartilage lesion of patella in adult males and females were 56.3% and 32.4%, respectively. Compared with adult females, adult males showed higher incidence of articular cartilage lesion of patella (P = 0.047). The incidence of VMO injury in adult males and females were 59.4% and 35.1%, respectively. Compared with adult females, adult males showed higher incidence of VMO injury (P = 0.044). No correlations were identified in other injuries in the adult group. CONCLUSIONS Compared with females, males predispose to complete MPFL tear and articular cartilage lesion of patella after acute LPD. Compared with female adults, male adults predispose to VMO injury.
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Affiliation(s)
- Lei Zheng
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Force, Jinan 250014, China
| | - Hong-Yu Ding
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated to Shandong First Medical University, Jinan 250014, China
| | - Yan Feng
- Department of Radiology, Affiliated Hospital of Binzhou Medical University, Binzhou 256600, China
| | - Bai-Sheng Sun
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Force, Jinan 250014, China
| | - Ling-Ling Zhu
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Force, Jinan 250014, China
| | - Guang-Ying Zhang
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated to Shandong First Medical University, Jinan 250014, China.
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20
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Egund N, Skou N, Jacobsen B, Jurik AG. Measurement of tibial tuberosity-trochlear groove distance by MRI: assessment and correction of knee positioning errors. Skeletal Radiol 2021; 50:751-759. [PMID: 32970161 DOI: 10.1007/s00256-020-03605-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The tibial tuberosity-trochlear groove (TTTG) distance varies with the position of the knee in the MR or CT scanner. We present and assess a simple method for adjustment of adduction or abduction of the knee. MATERIALS AND METHODS MRI of the knee encompassing a three-dimensional (3D) sagittal sequence including ≥ 8 cm of the proximal tibia was analyzed (29 females, 17 males; median age 45 years). Using 3D visualization software, the central longitudinal axis of the proximal tibia (TA) was constructed, and the TTTG distance was measured before and after alignment of the TA. Observer reliability was assessed with inter- and intra-class correlation coefficient (ICC) and Bland-Altman plots. RESULTS Adduction of the knee occurred in 26 examinations, mean 2.7° (range 0.0° to 9.4°), and abduction in 20 examinations, mean 2.6° (range 0.0° to 7.2°). Following adjustment, the mean TTTG distance increased 2.4 mm (range 0.0 to 6.7 mm) in the knees positioned in adduction and decreased 2.3 mm when in abduction (range 0.0 to 5.5 mm). The correlation coefficient (r2) between the deviation in adduction and abduction and the difference between TTTG unadjusted and adjusted was r2 = 0.96. ICCs were excellent, but limits of agreement were close to ± 3 mm. CONCLUSION Measurement of the TTTG distance by MRI is influenced by a systematic technique-dependent error caused by knee positioning in adduction or abduction. We suggest a simple method for adjusting the positioning.
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Affiliation(s)
- Niels Egund
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, Aarhus University Hospital, 8200, Aarhus, Denmark.
| | - Nikolaj Skou
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, Aarhus University Hospital, 8200, Aarhus, Denmark
| | - Bjarke Jacobsen
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, Aarhus University Hospital, 8200, Aarhus, Denmark
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, Aarhus University Hospital, 8200, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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21
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Agarwalla A, Yao K, Darden C, Gowd AK, Sherman SL, Farr J, Shubin Stein BE, Amin NH, Liu JN. Assessment and Trends of the Methodological Quality of the Top 50 Most Cited Articles on Patellar Instability. Orthop J Sports Med 2021; 9:2325967120972016. [PMID: 33614793 PMCID: PMC7869164 DOI: 10.1177/2325967120972016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
Background Studies with a low level of evidence (LOE) have dominated the top cited research in many areas of orthopaedics. The wide range of treatment options for patellar instability necessitates an investigation to determine the types of studies that drive clinical practice. Purpose To determine (1) the top 50 most cited articles on patellar instability and (2) the correlation between the number of citations and LOE or methodological quality. Study Design Cross-sectional study. Methods The Scopus and Web of Science databases were assessed to determine the top 50 most cited articles on patellar instability between 1985 and 2019. Bibliographic information, number of citations, and LOE were collected. Methodological quality was calculated using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS). Mean citations and mean citation density (citations per year) were correlated with LOE, MCMS, and MINORS scores. Results Most studies were cadaveric (n = 10; 20.0%), published in the American Journal of Sports Medicine (n = 13; 26.0%), published between 2000 and 2009 (n = 41; 82.0%), and conducted in the United States (n = 17; 34.0%). The mean number of citations and the citation density were 158.61 ± 59.53 (range, 95.5-400.5) and 12.74 ± 5.12, respectively. The mean MCMS and MINORS scores were 59.62 ± 12.58 and 16.24 ± 3.72, respectively. No correlation was seen between mean number of citations or citation density versus LOE. A significant difference was found in the mean LOE of articles published between 1990 and 1999 (5.0 ± 0) versus those published between 2000 and 2009 (3.12 ± 1.38; P = .03) and between 2010 and 2019 (3.00 ± 1.10; P = .01). Conclusion There was a shift in research from anatomy toward outcomes in patellar instability; however, these articles demonstrated low LOE and methodological quality. Higher quality studies are necessary to establish informed standards of management of patellar instability.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Kaisen Yao
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York, USA
| | - Christon Darden
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, New York, USA
| | - Anirudh K Gowd
- Department of Orthopedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Jack Farr
- Cartilage Restoration Center, OrthoIndy, Greenwood, Indiana, USA
| | | | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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Kluczynski MA, Miranda L, Marzo JM. Prevalence and Site of Medial Patellofemoral Ligament Injuries in Patients With Acute Lateral Patellar Dislocations: A Systematic Review and Meta-analysis. Orthop J Sports Med 2020; 8:2325967120967338. [PMID: 33403210 PMCID: PMC7747126 DOI: 10.1177/2325967120967338] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/19/2020] [Indexed: 01/11/2023] Open
Abstract
Background Medial patellofemoral ligament (MPFL) injuries are common in patients with acute lateral patellar dislocations, but the pattern of MPFL injuries is unclear, especially with respect to patient age. Purpose The primary aim was to determine the prevalence of MPFL injuries according to the site of injury in patients with acute lateral patellar dislocations. The secondary aim was to compare the site of MPFL injuries in patients aged ≤16 versus >16 years. Study Design Systematic review; Level of evidence, 4. Methods A systematic literature search was performed with PubMed, Embase, and CINAHL to identify articles published from January 1, 1999, to May 31, 2019, that examined the site of MPFL injuries in patients with acute patellar dislocations. The study design, sample size, age at injury, technique used for diagnosing MPFL injuries (magnetic resonance imaging, ultrasound, and/or surgery), and prevalence and site of MPFL injuries were extracted from each study. The pooled estimate of the proportion of MPFL injuries at each site was calculated (femur, patella, midsubstance, and combined sites of injury) as well as proportions stratified by age group (≤16 and >16 years). Results The literature search yielded 420 unique articles, of which 52 were screened for eligibility; of these, 17 were excluded. Thus, a total of 35 articles (2558 patients) were included in the final analysis. The overall prevalence of MPFL injuries was 94.7% (95% CI, 91.2%-96.8%). Most MPFL injuries occurred at the patella (37.1% [95% CI, 30.8%-43.9%]), followed by the femur (36.8% [95% CI, 31.0%-43.0%]), combined sites (25.1% [95% CI, 20.7%-30.1%]), and the midsubstance (15.6% [95% CI, 13.2%-18.4%]). In patients aged ≤16 years, most MPFL injuries occurred at the patella (39.3% [95% CI, 27.9%-51.9%]), and in patients aged >16 years, most MPFL injuries occurred at the femur (47.2% [95% CI, 40.6%-54.0%]). Conclusion The prevalence of MPFL injuries in patients with acute patellar dislocations varied by site of injury and by age. MPFL injuries at the patella were most prevalent overall and in children and adolescents, and MPFL injuries at the femur were more prevalent in adults.
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Affiliation(s)
- Melissa A Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Luis Miranda
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - John M Marzo
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
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23
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The majority of patellar avulsion fractures in first-time acute patellar dislocations included the inferomedial patellar border that was different from the medial patellofemoral ligament attachment. Knee Surg Sports Traumatol Arthrosc 2020; 28:3942-3948. [PMID: 32055875 DOI: 10.1007/s00167-020-05853-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/10/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE Accurate assessment of the locations of patellar avulsion fractures in acute patellar dislocations is clinically relevant for decision making for treatment. The study aim was to classify the locations of patellar avulsion fractures with a focus on the ligament attachments of medial stabilizing structures. METHODS Out of 131 first-time acute traumatic patellar dislocations, 61 patients had patellar fractures. Subsequently, 10 patients with isolated osteochondral fractures of the articular surface in the patella were excluded. Finally, 51 patients (34 females and 17 males, average age: 18.5 years, 95% CI 16.1-20.9) were included in the study cohort. Based on the locations of the patellar attachment, the patients were divided into three groups: the superior group [medial patellofemoral ligament (MPFL) attachment], inferior group [medial patellotibial ligament (MPTL)/medial patellomeniscal ligament (MPML) attachment], and mixed group. RESULTS In the patellar avulsion group (51 patients), the superior group, mixed group, and inferior group contained 8/51 (16%), 12/51 (24%), and 31/51 (61%) patients, respectively. CONCLUSIONS This study showed that 84% of the patellar avulsion fractures were located in the inferomedial patellar border, which consisted of MPTL/MPML attachments that were clearly different from the true "MPFL" attachment at the superomedial patellar border. In terms of the clinical relevance, the acute surgical repair of MPTL/MPML attachments in the inferomedial patellar border may not sufficiently control the patella if optimal management of the MPFL is not performed. LEVEL OF EVIDENCE IV.
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24
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Mayer P, Schuster P, Schlumberger M, Eichinger M, Pfaff M, Immendörfer M, Richter J. Midterm Results after Implant-Free Patellar Fixation Technique for Medial Patellofemoral Ligament Reconstruction. J Knee Surg 2020; 33:1140-1146. [PMID: 31269526 DOI: 10.1055/s-0039-1692654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Problems and complications concerning the patellar fixation in medial patellofemoral ligament reconstruction (MPFLR) have been reported. The purpose of this retrospective study was to systematically analyze the surgical technique for MPFLR with a V: -shaped patellar bonetunnel for implant-free fixation of an autologous gracilis tendon, allowing early functional rehabilitation, regarding restoration of the patellofemoral stability, patient satisfaction, return to sports, and technique-specific complications. In 2010, 128 cases of consecutive isolated MPFLR were performed. All these cases were included. After a minimum follow-up of 3 years, 104 cases were retrospectively analyzed (follow-up: 81.3%) with regard to redislocation, subjective functional outcome (Tegner's score and sports level compared with preoperative level), patient satisfaction, revision surgery, and technique-specific complications. After a follow-up of 45.7 ± 3.2 months, 101 of 104 cases (97.1%) showed no redislocation. Mean Tegner's score was 5.1 ± 1.8 (range, 2-9). A total of 61.5% patients reported about a higher sports level compared with their preoperative level. The patient satisfaction was high with 94.2%. In two cases (1.9%), technique-specific problems occurred as the bone bridge of the V: -shaped tunnel was insufficient due to a malpositioning of the aiming device. No further technique-specific problems occurred and no revision surgery was necessary during the observational period. The presented surgical technique is safe and it reliably restores the patellofemoral stability, with a low rate of redislocations, an excellent subjective functional outcome, and a high-patient-reported satisfaction. No major technique-specific complications occurred.
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Affiliation(s)
- Philipp Mayer
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Philipp Schuster
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany.,Paracelsus Medical Private University, Clinic Nuremberg Departement of Orthopedics and Traumatology, Nuremberg, Germany
| | - Michael Schlumberger
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Martin Eichinger
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Michael Pfaff
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Micha Immendörfer
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Jörg Richter
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
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25
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Recurrent Patellar Dislocations Without Untreated Predisposing Factors: Medial Patellofemoral Ligament Reconstruction Versus Other Medial Soft-Tissue Surgical Techniques-A Meta-analysis. Arthroscopy 2020; 36:1725-1734. [PMID: 32001279 DOI: 10.1016/j.arthro.2019.12.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE To provide a direct comparison between medial patellofemoral ligament (MPFL) reconstruction and the other medial patellofemoral soft-tissue surgeries in the restoration of the medial patellar restraint after lateral patellar dislocations in the absence of untreated predisposing factors such as high grade trochlear dysplasia, knee malalignment, patella alta or high tibial tubercle-trochlear groove distance. METHODS PubMed, Cochrane-library, Web of Science, and gray literature databases were searched to find all the relevant records. Study selection, data extraction, and risk of bias assessment were performed following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Different techniques to treat lateral patellar dislocation in the absence of untreated predisposing factors were compared in terms of redislocation and complication rates, Kujala, Lysholm, International Knee Documentation Committee, and Tegner scores at the short-term (3 years) and long-term (>3 years) follow-up through meta-analyses. RESULTS Six studies involving 319 knees were included in the meta-analysis. The analyses of redislocation (0.7% vs 2.9%) and minor complication rates (12% vs 9%) showed no significant differences between MPFL reconstruction and other medial soft-tissue surgeries. Significant differences favoring MPFL reconstruction were documented in Kujala and Lysholm scores at short-term (8.6, P< .001; 10.9, P < .001) and long-term follow-ups (6.3, P = .02; 13.5, P < .001). No significant differences were found in the analyses of International Knee Documentation Committee (P = .10) and Tegner scores (P = .19). Level of evidence was low or very low. CONCLUSIONS MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent LPD. LEVEL OF EVIDENCE Level III (meta-analysis of randomized and nonrandomized comparative trials).
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26
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Frings J, Balcarek P, Tscholl P, Liebensteiner M, Dirisamer F, Koenen P. Conservative Versus Surgical Treatment for Primary Patellar Dislocation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:279-286. [PMID: 32519945 PMCID: PMC7370958 DOI: 10.3238/arztebl.2020.0279] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 08/14/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Primary patellar dislocation is often the initial manifestation of patellofemoral instability. Its long-term consequences can include recurrent dislocation and permanent dysfunction of the knee joint. There is no consensus on the optimal treatment of primary patellar dislocation in the relevant literature. The main prerequisite for a good long-term result is a realistic assessment of the risk of recurrent dislocation. METHODS We carried out a systematic literature search in OvidSP (a search engine for full-text databases) and MEDLINE to identify suitable stratification models with respect to the risk of recurrent dislocation. RESULTS In the ten studies included in the current analysis, eight risk factors for recurrence after primary patellar dislocation were identified. Six studies revealed a higher risk in younger patients, particularly those under 16 years of age. The sex of the patient had no clear influence. In two studies, bilateral instability was identified as a risk factor. Two anatomical risk factors-a high-riding patella (patella alta) and trochlear dysplasia-were found to have the greatest influence in six studies. In a metaanalysis of five studies, patella alta predisposed to recurrent dislocation with an odds ratio (OR) of 4.259 (95% confidence interval [1.9; 9.188]). Moreover, a pathologically increased tibial tuberosity to trochlear groove (TT-TG) distance and rupture of the medial patellofemoral ligament (MPFL) on the femoral side were associated with higher recurrence rates. Patients with multiple risk factors in combination had a very high risk of recurrence. CONCLUSION The risk of recurrent dislocation after primary patellar dislocation is increased by a number of risk factors, and even more so when multiple such risk factors are present. Published stratification models enable an assessment of the individual risk profile. Patients at low risk can be managed conservatively; surgery should be considered for patients at high risk.
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Affiliation(s)
- Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | | | - Philippe Tscholl
- Department of Orthopedic Surgery and Musculoskeletal Trauma Care Division, HUG-Hôpitaux Universitaires Genève, Geneva, Switzerland
| | - Michael Liebensteiner
- Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Dirisamer
- Orthopedics & Sports Medicine Linz, UMIT – Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria
| | - Paola Koenen
- Department of Orthopedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - on behalf of the AGA Knee Patellofemoral Committee
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- ARCUS Kliniken Pforzheim, Pforzheim, Germany
- Department of Orthopedic Surgery and Musculoskeletal Trauma Care Division, HUG-Hôpitaux Universitaires Genève, Geneva, Switzerland
- Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Orthopedics & Sports Medicine Linz, UMIT – Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria
- Department of Orthopedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
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An VV, Sivakumar BS, Phan K, Fritsch BA, Sher D. Isolated versus combined medial patellofemoral ligament reconstruction for lateral instability of the patella. J Orthop Surg (Hong Kong) 2020; 27:2309499018820698. [PMID: 30798706 DOI: 10.1177/2309499018820698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Medial patellofemoral ligament reconstruction (MPFLR) is regularly combined with a tibial tuberosity transfer (TTT) in cases of recurrent patellar instability with underlying structural deformity. However, these indications for a TTT have recently come into question. This study aimed to assess the traditional indications by comparing the outcomes of isolated and combined MPFLR for the treatment of recurrent lateral patellar dislocation. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies were those which reported the outcomes of either isolated or combined or both MPFLR. Studies were required to report at least one of the following: redislocation rate, revision due to instability, or the Kujala score. RESULTS We found no difference between isolated and combined MPFLR in terms of redislocation ( p = 0.48), revisions due to instability ( p = 0.36), positive apprehension tests ( p = 0.25), or the Kujala score ( p = 0.58). Combined reconstruction presented more complications compared to isolated procedures ( p = 0.05). Subgroup analysis revealed no significant difference between studies investigating isolated medial patellofemoral ligament reconstruction MPFLR performed in patients with normal tibial tuberosity-trochlear groove (TT-TG) distances only or in patients with both normal and elevated TT-TG distances. CONCLUSIONS According to the published data, there is no difference in outcomes between isolated and combined MPFLR. Underlying structural deformity did not demonstrate any significant effect on the success of the isolated MPFLR. Although there are definite indications for combined reconstruction, the current evidence suggests that our inclusion criteria may not be entirely correct. Further study is required to clarify and refine the true indications for combined MPFLR. LEVEL OF EVIDENCE III, meta-analysis of nonrandomized studies.
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Affiliation(s)
- Vincent Vg An
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- 2 Department of Orthopaedics, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Kevin Phan
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brett A Fritsch
- 3 Department of Orthopaedics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Doron Sher
- 4 Department of Orthopaedics, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Hiemstra LA, Kerslake SA, Lafave MR. Influence of Risky Pathoanatomy and Demographic Factors on Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction: A Regression Analysis. Am J Sports Med 2019; 47:2904-2909. [PMID: 31411896 DOI: 10.1177/0363546519866452] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple studies have demonstrated that a number of demographic and pathoanatomic characteristics are associated with patellofemoral instability, recurrence of instability, and less satisfactory results following medial patellofemoral ligament reconstruction (MPFL-R). Despite the growing volume of research, the relationship of risk factors to patient-reported outcome after MPFL-R is unclear. PURPOSE To determine if certain pathoanatomic and demographic factors predict disease-specific quality-of-life outcome after isolated MPFL-R for symptomatic patellofemoral instability. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study analyzed 224 isolated MPFL-Rs. Demographic data were collected, including age at first dislocation, sex, and presence of bilateral instability. Pathoanatomic risk factors included the presence of high-grade trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patella alta ratio, Beighton score, and patellar tilt. Other factors included femoral tunnel position accuracy and WARPS/STAID score. Descriptive analyses were conducted, followed by calculation of individual Spearman rank correlation coefficients for the predictor variables versus the Banff Patellofemoral Instability Instrument (BPII) scores. A multivariable regression with stepwise selection was employed to establish the final model predicting BPII score, with all significant variables for alpha ≤ .05 included in the final model. RESULTS The cohort of 224 patients included 66 (29.5%) males and 158 (70.5%) females, with a mean age of 24.1 years and a mean body mass index of 23.9 kg/m2. The mean age of first patellar dislocation was 15.7 years, and 41.4% of patients had bilateral instability. Pathoanatomic variables within the cohort included the following: high-grade trochlear dysplasia = 41%; mean TT-TG = 14.6 mm, with 16.8% of patients demonstrating a TT-TG ≥18 mm; mean Caton-Deschamps ratio = 1.09, with 22% of patients demonstrating a ratio ≥1.2; and positive Beighton score = 37.5%. The mean BPII score at postoperative 2 years was 67.1 out of 100. A stepwise elimination in the regression model demonstrated no statistically significant 3- or 2-way relationships. Assessment of individual variables indicated that bilateral symptoms (P = .004), higher age at first dislocation (P = .024), and femoral tunnel position >10 mm from the Schöttle point (P = .042) were statistically significant predictors of lower quality-of-life scores. The R2 value for the regression analysis model was 0.07. CONCLUSION In this large cohort of patients undergoing isolated MPFL-R for symptomatic lateral patellofemoral instability, a multivariable forward stepwise regression demonstrated that bilateral symptoms, femoral tunnel position, and age at first dislocation were statistically significant predictors of lower postoperative BPII scores. No anatomic risk factors were predictive of quality-of-life outcome score 2 years after MPFL-R surgery. The R2 value indicated that there were many other important contributing factors affecting BPII outcome scores than those explored in this study.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine, Banff, Canada.,Department of Surgery, University of Calgary, Calgary, Canada
| | | | - Mark R Lafave
- Department of Physical Education and Recreation Studies, Mount Royal University, Calgary, Canada
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Yang Y, Zhang Q. Reconstruction of the medial patellofemoral ligament and reinforcement of the medial patellotibial ligament is an effective treatment for patellofemoral instability with patella alta. Knee Surg Sports Traumatol Arthrosc 2019; 27:2599-2607. [PMID: 30421164 DOI: 10.1007/s00167-018-5281-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/29/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate the clinical outcome of the combined reconstruction of the medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) for patellar instability with patella alta. METHODS A total of 108 patients underwent a combined reconstruction of the MPFL and MPTL, and 58 patients were included in this study. The clinical results were evaluated and compared using the International Knee Documentation Committee (IKDC) scores, Kujala scores, and visual analogue scale (VAS) scores. The tibial tuberosity-trochlear groove (TT-TG) distance, three indices of patellar height (Insall-Salvati ratio, modified Insall-Salvati ratio, and Caton-Deschamps index), and patellar shift and tilt were defined preoperatively and at the 12- and 24-month follow-up visits. RESULTS At the 12- and 24-month follow-up visits, 86.2% (50/58) and 87.9% (51/58) of the subjective outcomes were excellent, 5/58 (8.6%) and 4/58 (6.9%) were good, 1/58 (1.7%) and 2/58 (3.4%) were fair, and 2/58 (3.4%) and 1/58 (1.7%) were poor. There were significant improvements in the IKDC scores, from 51.9 ± 13.8 preoperatively to 80 ± 19.2 (P < 0.05) at 12 months and 85 ± 13.9 (P < 0.05) at 24 months; Kujala scores, from 55.1 ± 15.2 preoperatively to 82.6 ± 14.9 (P < 0.05) at 12 months and 89.5 ± 10.2 (P < 0.05) at 24 months; and VAS scores, from 58 ± 11 preoperatively to 12 ± 5 (P < 0.05) at 12 months and 11 ± 4 (P < 0.05) at 24 months. The patellar tilt, patellar shift, Insall-Salvati ratio, modified Insall-Salvati ratio, Caton-Deschamps index, and TT-TG distance all decreased significantly compared with the preoperative values, and there were no significant differences between the values at the 12- and 24-month follow-ups. CONCLUSION The results of this study show that a combined reconstruction of the MPFL and MPTL is an effective treatment for patellar instability with patella alta. This article emphasizes the combined effect of MPFL and MPTL instead of MPFL alone and provides an effective option for the treatment of recurrent patellar dislocation with patella alta. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yimeng Yang
- Department of Orthopedics, The General Hospital of Chinese People's Liberation Army, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Qiang Zhang
- Department of Orthopedics, The General Hospital of Chinese People's Liberation Army, 28 Fuxing Road, Haidian District, Beijing, 100853, China. .,Department of Orthopaedic Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, UK.
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30
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Grimm NL, Wooster BM, Tainter DM, Kildow BJ, Kim J, Taylor DC. Anatomic Magnetic Resonance Imaging Measurements in First-Time Patellar Dislocators by Sex and Age. J Athl Train 2019; 54:901-905. [PMID: 31355669 DOI: 10.4085/1062-6050-280-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
CONTEXT Anatomic differences of the knee in first-time patellar dislocators have not been clearly elucidated. OBJECTIVE To compare structural differences of the knee in those who have sustained an acute first-time patellar dislocation resulting in a medial patellofemoral ligament (MPFL) tear by sex and age (≤17 years old, ≥18 years old). DESIGN Case series. SETTING Retrospective magnetic resonance imaging analysis. PATIENTS OR OTHER PARTICIPANTS Thirty-five acute first-time patellar dislocators with an associated MPFL tear. MAIN OUTCOME MEASURE(S) Patellar height using 3 methods, patellar alignment using congruency angles, and trochlear morphology using the sulcus angle. We compared the means of these variables by sex and age. The intraclass correlation coefficient was then calculated to assess the agreement of the independent reviewers. RESULTS A total of 21 left and 14 right knees were analyzed. The MPFL tear location did not differ by sex (P = .34) or age (P = .43). Patellar height did not differ as measured by the Caton-Deschamps ratio (P = .29 for sex, P = .49 for age), Insall-Salvati index (P = .15 for sex, P = .33 for age), or patellotrochlear index (P = .67 for sex, P = .49 for age). The congruence angle (P = .81 for sex, P = .06 for age) and trochlear morphology as measured by the sulcus angle (P = .64 for sex, P = .45 for age) were similar between groups. CONCLUSIONS Patellar height and trochlear morphology did not differ by sex or age among patients whose first-time patellar dislocations resulted in an MPFL tear. In addition, the location of the tear did not appear to vary by sex or age.
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Affiliation(s)
- Nathan L Grimm
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Benjamin M Wooster
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David M Tainter
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Beau J Kildow
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Jaewhan Kim
- Division of Public Health, Study Design, and Biostatistics Center, University of Utah School of Medicine, Salt Lake City
| | - Dean C Taylor
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Vairo GL, Moya-Angeler J, Siorta MA, Anderson AH, Sherbondy PS. Tibial Tubercle-Trochlear Groove Distance Is a Reliable and Accurate Indicator of Patellofemoral Instability. Clin Orthop Relat Res 2019; 477:1450-1458. [PMID: 31094842 PMCID: PMC6554121 DOI: 10.1097/corr.0000000000000711] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 02/14/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial tubercle-trochlear groove (TT-TG) distance is a measurement generally made on CT scans that is commonly used to quantify the risk of patellofemoral instability (PFI); however, its interrater reliability and accuracy as an indicator of PFI in patients is poorly characterized. QUESTIONS/PURPOSES The purposes of our study were (1) to primarily analyze interrater reliability of the TT-TG distance among orthopaedists with varied experience as measured by MRI, (2) to secondarily compare TT-TG distances between PFI and control groups, and (3) to determine an accurate TT-TG distance threshold indicative of PFI. METHODS The electronic medical records of a senior fellowship-trained orthopaedic sports medicine surgeon were surveyed between 2012 and 2016 for patients who had experienced at least one episode of patellar subluxation or dislocation, who reported no other knee-related history, and who underwent MRI due to persistent PFI signs and symptoms. The records of 48 PFI patients (23 males, 25 females; 19 ± 4 years of age) were compared with 83 controls (60 males, 23 females; 31 ± 8 years of age) having no history of PFI, presenting with an isolated meniscal lesion as determined from MRI and treated by the same orthopaedist during this time. All records meeting study criteria were consecutively included to offset selection bias of the retrospective analysis. Two sports medicine fellows, one who had just completed orthopaedic residency training, and another with a year of experience after residency, and a sports medicine subspecialist with more than 15 years of experience in practice independently recorded TT-TG distance, indicative of tibial tubercle lateralization relative to the femoral trochlea, to the nearest millimeter (mm) in a blinded and randomized fashion. Intraclass correlation coefficient computed interrater reliability accompanied by standard error of measurement (SEM); a one-tailed, two-sample t-test analyzed group differences with accompanying effect size per Cohen's d; receiver operating characteristic (ROC) curve determined accuracy and threshold for PFI risk. A p value < 0.05 denoted statistical significance. RESULTS Interrater reliability was excellent, at 0.93 (95% confidence interval [CI], 0.84-0.97; SEM = 0.6 mm) for PFI patients and 0.95 (95% CI, 0.91-0.97; SEM = 0.4 mm) for controls. Distance was greater (95% CI, 2-5; p < 0.001) in PFI patients (14 ± 4 mm; range = 7-24 mm) than controls (10 ± 3 mm; range = 3-19 mm) with an effect size of 1 (95% CI, 0.3-2). Area under the ROC curve was 0.75 (95% CI, 0.66-0.83) and threshold was 13 mm (sensitivity = 0.52, 1-specificity = 0.25), suggesting the measure is a fairly accurate indicator of risk and values of 13 mm or greater are better suited to rule in PFI. Respective positive and negative likelihood ratios of 2 and 0.6 at this threshold confirm that this distance yields a small increase in probability for PFI and a minimal decrease in probability for risk; specifically, a 13-mm TT-TG distance is two times more likely to be found in patients with PFI. Furthermore, this threshold is estimated to increase a correct PFI diagnosis by approximately 15%. CONCLUSIONS The MRI-specific TT-TG distance, based on a single measurement using cartilaginous-tendon landmarks within a standardized trochlear range, is reliable as performed by orthopaedists of varied experience. Patients with PFI display a 4-mm greater distance than controls, which may represent a difference large enough for clinicians to discern in practice using MRI. A 13-mm TT-TG distance is two times more likely seen in patients with PFI. However, this threshold increases a correct PFI diagnosis by only about 15%; therefore, clinical decision-making should not be influenced by this criterion alone and instead used in conjunction with other relevant variables. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Affiliation(s)
- Giampietro L Vairo
- G. L. Vairo, Departments of Kinesiology and Orthopaedics & Rehabilitation, Colleges of Health & Human Development, and Medicine, The Pennsylvania State University, University Park, PA, USA J. Moya-Angeler, M. A. Siorta, A. H. Anderson, P. S. Sherbondy, Department of Orthopaedics & Rehabilitation, College of Medicine, The Pennsylvania State University, University Park, PA, USA
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Medial Patellofemoral Ligament Reconstruction: A Comparison of Single-Bundle Transpatellar Tunnel and Double-Anchor Anatomic Techniques for the Treatment of Recurrent Lateral Patellar Dislocation in Adults. Arthroscopy 2019; 35:845-854.e1. [PMID: 30704885 DOI: 10.1016/j.arthro.2018.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the stability and clinical outcomes of 2 medial patellofemoral ligament reconstruction (MPFLR) techniques for the treatment of recurrent lateral patellar dislocation in adults. METHODS Ninety-one patients with recurrent patellar dislocation were randomly divided into 2 groups, undergoing either the traditional single-bundle transpatellar tunnel technique (group A) or the double-anchor anatomic reconstruction technique (group B). Preoperatively and at follow-up, the patellar position and rotation were evaluated by computed tomography with the congruence angle, lateral patellar angle, patellar tilt angle, and lateral patellar translation; the subjective symptoms and functional outcomes were evaluated with Kujala, Lysholm, Tegner, and International Knee Documentation Committee subjective scores. Clinical examinations were also performed, and redislocations or episodes of instability were recorded. RESULTS Patients were followed up for a mean period of 41.11 ± 7.40 months (range, 29-62 months). At the final point, no recurrent patellar dislocations occurred, except in 4 patients with instability symptoms in group A; however, no significant difference between the 2 groups was seen (χ2 = 2.503, P = .114). The measurement results from computed tomography decreased significantly to the normal range, and no significant difference was found between the 2 groups except for the lesser patellar tilt angle in group B (t = 2.175, P = .030). The clinical examination improved significantly, no patient exhibited a positive apprehension test in either group, and the number of patients with abnormal lateral patellar translation grade and firm end point showed no statistically significant differences between the 2 groups (P > .05). All score systems significantly improved with no significant difference between the 2 groups except for the higher Kujala score (t = -40.635, P = .001) and International Knee Documentation Committee score (t = -33.823, P = .003) in group B. CONCLUSIONS Both MPFLR techniques achieved good results in the treatment of patellar dislocation. Compared with the single-bundle transpatellar tunnel technique, the double-anchor anatomic MPFLR technique may be more effective with a more congruous patellofemoral joint and better knee function. LEVEL OF EVIDENCE Level II, prospective comparative study.
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The reversed dynamic patellar apprehension test mimics anatomical complexity in lateral patellar instability. Knee Surg Sports Traumatol Arthrosc 2019; 27:604-610. [PMID: 30293182 DOI: 10.1007/s00167-018-5198-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/02/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE To develop a dynamic physical examination test that functionally simulates actual patellar instability events and that mimics the range of patellar stabilizer insufficiency in an individual patient. METHODS Seventy-eight consecutive patients (male/female 35/43; mean age 22 ± 7 years) with recurrent lateral patellar instability and 35 controls (male/female 16/19; mean age 31 ± 14 years) were prospectively evaluated using the reversed dynamic patellar apprehension test (ReDPAT). Anatomical predisposition was assessed according to Dejour's classification of trochlear dysplasia, tibial tuberosity-trochlear groove distance, tibial tuberosity-posterior cruciate ligament distance, patellar height, and varus/valgus malalignment. RESULTS The study group had an average of 3.4 ± 1.0 (1-6) anatomical risk factors for lateral patellar dislocation. Severe trochlear dysplasia (84%) and patella alta (49%) were the most common. Test sensitivity and specificity was 93.7% (95% CI 0.8584-0.9791) and 88.2% (95% CI 0.7255-0.9670), respectively. The positive predictive value reached 94.9% (95% CI 0.8739-0.9859) and the negative predictive value was 85.7% (95% CI 0.6974-0.9519). The ReDPAT results became positive at a mean knee flexion angle of 58° ± 17° (20°-90°). Knee flexion angle correlated significantly with the severity of trochlear dysplasia (p = 0.018), valgus deformity (p = 0.011), and the total number of anatomical risk factors (p = 0.02). CONCLUSION This study introduced the reversed dynamic patellar apprehension test as a reliable clinical examination tool in the assessment of lateral patellar instability. The results of this study indicate that the degree of knee joint flexion at which the provocative sense of apprehension becomes positive correlates with severity of trochlear dysplasia, valgus deformity and the total number of anatomical risk factors for patellar instability. This test indicates the patient-specific end of stable patellar tracking and the beginning of patellar stabilizer insufficiency. Therefore, this test might be helpful in deciding for or against a bony procedure in the treatment of patellar dislocation. LEVEL OF EVIDENCE II.
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A new classification of injury patterns of the medial patellofemoral ligament after acute lateral patella dislocation detected using magnetic resonance imaging studies. Injury 2019; 50:534-540. [PMID: 30466734 DOI: 10.1016/j.injury.2018.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/28/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute lateral patellar dislocation is a very common condition in orthopedics, especially among adolescents and physically active patients. To evaluate distinct medial patellofemoral ligament (MPFL) injury patterns and the associated knee pathology after acute lateral patellar dislocation (ALPD) using magnetic resonance imaging (MRI) studies, which is essential for the development of treatment protocols. MATERIALS AND METHODS MRI images of 74 ALPD patients were taken between January 2015 to December 2016. Images were evaluated using standardized protocols. RESULTS The prevalence of MPFL injury following ALPD was 97.3% (72/74 patients). Among the 72 patients with MPFL, the prevalence of Type Ⅰ injury was 26.4% (19/72). Since only bone marrow edema and a partial tear were showed on MRI of these patients, conservative treatment was given. Tear of the MPFL occurred at the patellar attachment (Type Ⅱa) in 16 patients (16/72, 22.2%), at the middle area of the ligament (Type Ⅱb) in 5 patients (5/72, 6.9%), and at the femoral attachment (Type Ⅱc) in 27 patients (27/72, 37.5%). For Type Ⅱ injuries, all patients had the surgery to reconstruct the MPFL. The prevalence of Type Ⅲ MPFL injury was 6.9% (5/72) after the surgery. CONCLUSION MPFL injury of is a common sequel following ALPD. We assessed the distinct injury pattern and associated pathology of MPFL using MRI studies. A good understanding of the injury pattern and associated knee pathology of MPFL is essential in managing patients with ALPD, especially if surgical intervention is considered.
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Incidence of second-time lateral patellar dislocation is associated with anatomic factors, age and injury patterns of medial patellofemoral ligament in first-time lateral patellar dislocation: a prospective magnetic resonance imaging study with 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 2019; 27:197-205. [PMID: 30008056 DOI: 10.1007/s00167-018-5062-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/11/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To examine the predictors of the second-time lateral patellar dislocation (LPD) in patients after acute first-time LPD in a 5-year follow-up. METHODS Data were collected prospectively from patients after acute first-time LPD with conservative treatment. Factors included sex, age at the first-time LPD, anatomical variants [trochlear dysplasia, patellar height, tibial tuberosity-trochlear groove (TT-TG) distance], and injury patterns of medial patellofemoral ligament (MPFL) in acute first-time LPD. Logistic regression was carried out to identify the independent risk factors for the incidence of the second-time LPD. RESULTS The incidence rate of a second-time LPD was 35.5% (59 of 166) in the 5-year follow-up. Univariate analysis revealed significant differences in the incidence rate of the second-time LPD among age at the first-time LPD (P = 0.04), trochlear dysplasia (P = 0.003), patella height (P = 0.017) and the TT-TG distance (P = 0.027). Risk factors for the second-time LPD were age < 18 years at the first-time LPD [odds ratio (OR) 4.088], low-grade trochlear dysplasia (OR 7.214), high-grade trochlear dysplasia (OR 18.945), patella alta (OR 8.416), elevated TT-TG distance (OR 12.742), complete MPFL tear at its isolated femoral-side (OR 6.04) and complete combined MPFL tear (OR 5.851). CONCLUSIONS Trochlear dysplasia, elevated TT-TG distance, patella alta, age < 18 years at the first-time LPD, complete MPFL tear at its isolated femoral-side and complete combined MPFL tear in the first-time LPD are independently associated with a higher incidence rate of the second-time LPD. LEVEL OF EVIDENCE III.
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Arendt EA, Askenberger M, Agel J, Tompkins MA. Risk of Redislocation After Primary Patellar Dislocation: A Clinical Prediction Model Based on Magnetic Resonance Imaging Variables. Am J Sports Med 2018; 46:3385-3390. [PMID: 30398902 DOI: 10.1177/0363546518803936] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND First-time lateral patellar dislocations have historically been treated with a nonoperative approach; a clinical tool to predict patients who are most likely to redislocate may have clinical utility. PURPOSE (1) To determine if there are discriminating factors present between patients who redislocated their patellas and those who did not after a first-time lateral patellar dislocation and (2) to use this information to develop a model that can predict the recurrence risk of lateral patellar dislocation in this population. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS The study population included those with first-time lateral patellar dislocation, magnetic resonance imaging within 6 weeks, and 2-year minimum follow-up. Cohort A was from a prospective study with 2-year follow-up. Cohort B was a prospectively identified cohort with retrospective chart review. Follow-up was obtained clinically or via mail for patients without 2-year clinical follow-up. RESULTS Sixty-one patients (42%) out of 145 with primary lateral patellar dislocation had recurrent dislocation within 2 years. Stepwise logistic regression analysis demonstrated that skeletal immaturity (odds ratio, 4.05; 95% CI, 1.86-8.82; P = .0004), sulcus angle (odds ratio, 4.87; 95% CI, 2.01-11.80; P = .0005), and Insall-Salvati ratio (odds ratio, 3.0; 95% CI, 1.34-6.70; P = .0074) were significant predictors of redislocation. Receiver operator characteristic curves defined the cut points to be sulcus angle ≥154° and Insall-Salvati ratio ≥1.3. The probability of redislocation based on the presence of factors was 5.8% with no factors present and 22.7% with any 1 factor present, increasing to 78.5% if all 3 factors were present. CONCLUSION This model demonstrates a high risk of lateral patellar redislocation when a patient presents with skeletal immaturity as well as magnetic resonance measurements of sulcus angle ≥154° and patellar height as measured by Insall-Salvati ratio ≥1.3. A patient will have a low risk of lateral patellar redislocation with the inverse findings.
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Affiliation(s)
- Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Julie Agel
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- TRIA Orthopaedic Center, Bloomington, Minnesota, USA
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Surgical medial patellofemoral ligament reconstruction versus non-surgical treatment of acute primary patellar dislocation: a prospective controlled trial. INTERNATIONAL ORTHOPAEDICS 2018; 43:1495-1501. [DOI: 10.1007/s00264-018-4243-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/14/2018] [Indexed: 12/28/2022]
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Roessler PP, Wimmer MD, Jacobs C, Bornemann R, Stein T, Lahner M. Medial patellofemoral ligament reconstruction fails to correct mild patella alta in cases of patellofemoral instability-a case-control study. INTERNATIONAL ORTHOPAEDICS 2018; 43:2071-2075. [PMID: 30225588 DOI: 10.1007/s00264-018-4162-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/12/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Medial patellofemoral ligament reconstruction (MPFL-R) is the gold standard in patella soft tissue surgery for patellofemoral instability. Although claimed, recent reports indicate that MPFL-R may fail to distalize the patella in mild cases of patella alta. The present study is a retrospective case-control study to compare radiographic patella height between MPFL-R and historical Insall's proximal realignment (IPR) pre- and post-operatively with respect to distalization and assess redislocation rates at a mid-term follow-up. METHODS Sixty-four patients were age/sex matched (1:1), yielding 32 patients for group 1 MPFL-R (cases) and 32 patients for group 2 IPR (controls). Insall-Salvati, Blackburne-Peel and Caton-Deschamps indices were analyzed for differences pre- and post-operatively. An additional inter-rater reliability analysis was performed by means of intra-class correlation (ICC). Redislocation rates were considered as treatment failures in this study. RESULTS ICC was excellent for all three patella indices. MPFL-R failed to show significant differences if compared to IPR with respect to distalization in mild stages of patella alta. Moreover, redislocation rates significantly favored MPFL-R (3.1%) over IPR (12.5%; p < 0.0001). CONCLUSIONS MPFL-R has become a popular option to restore native patellofemoral biomechanics after ligament rupture. However, the procedure's potential to correct concomitant patella alta should not be overestimated and indications considered carefully.
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Affiliation(s)
- Philip P Roessler
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - Matthias D Wimmer
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Cornelius Jacobs
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Rahel Bornemann
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Thomas Stein
- Department of Sporttraumatology, Knee and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Matthias Lahner
- Joint Center Hilden, Ruhr-University Bochum, Bochum, Germany
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Lee DK, Wang JH, Kang SH, Kim JH, Haque R, Lee BH. The clinical and radiological results of individualized surgical treatment depending on pathologic abnormalities in recurrent patellar dislocation: low recurrence rate, but unintended patella baja. Knee Surg Sports Traumatol Arthrosc 2018; 26:2558-2567. [PMID: 28914334 DOI: 10.1007/s00167-017-4697-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 08/23/2017] [Indexed: 01/17/2023]
Abstract
PURPOSE To evaluate the clinical and radiological outcomes and chondral lesion change using individualized surgery for recurrent patellar dislocation. METHODS A total of 31 knees with recurrent patellar dislocation underwent surgery depending on individual pathologic abnormalities. Pathologic abnormalities including medial laxity, lateral tightness, increased tibial tuberosity (TT)-to-trochlear groove distance (>20 mm), and patella alta (Caton-Deschamps ratio >1.2) were evaluated in each patient. The abnormalities were corrected through medial patellofemoral ligament reconstruction, TT distalization, TT anteromedialization, and lateral retinacula release. The mean follow-up period was 33 months. RESULTS There was one recurrent case (3.2%), requiring additional surgery. The mean Kujala scores were significantly (P = 0.002) improved from 75.8 (SD 12.4) to 84.6 (SD 13.1). Tegner scores were significantly improved from 3.7 (range 1-9) to 5.4 (range 2-9) (P < 0.001), as were and visual analogue scale pain scores from 4.7 (SD 2.5) to 2.6 (SD 2.2) (P = 0.001). Caton-Deschamps ratio was significantly decreased from 1.1 (SD 0.2) to 0.9 (SD 0.1) (P < 0.001), regardless of TT distalization. Chondral lesions of the patella and trochlear groove were improved or maintained in 57.1 and 71.4% of patients, respectively. CONCLUSION Individualized surgery in recurrent patellar dislocation was effective and safe with a low recurrence rate. However, the possibility of unintended patella baja, which might be related to post-operative anterior knee pain, should be considered. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Konyang University Hospital, Konyang University School of Medicine, Daejeon, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center and Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Seung Hoon Kang
- Department of Orthopedic Surgery, Samsung Changwon hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Russel Haque
- Department of Orthopedic Surgery, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
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Askenberger M, Bengtsson Moström E, Ekström W, Arendt EA, Hellsten A, Mikkelsen C, Janarv PM. Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial. Am J Sports Med 2018; 46:2328-2340. [PMID: 29847145 DOI: 10.1177/0363546518770616] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. PURPOSE (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. RESULTS The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. CONCLUSION Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).
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Affiliation(s)
- Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital, Solna, Sweden
| | - Eva Bengtsson Moström
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital, Solna, Sweden
| | - Wilhelmina Ekström
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | | | - Christina Mikkelsen
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.,Capio Artro Clinic, Stockholm, Sweden
| | - Per-Mats Janarv
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.,Capio Artro Clinic, Stockholm, Sweden
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Fu K, Duan G, Liu C, Niu J, Wang F. Changes in femoral trochlear morphology following surgical correction of recurrent patellar dislocation associated with trochlear dysplasia in children. Bone Joint J 2018; 100-B:811-821. [PMID: 29855234 DOI: 10.1302/0301-620x.100b6.bjj-2017-1295.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Aims The aim of this study was to investigate the changes in femoral trochlear morphology following surgical correction of recurrent patellar dislocation associated with trochlear dysplasia in children. Patients and Methods A total of 23 patients with a mean age of 9.6 years (7 to 11) were included All had bilateral recurrent patellar dislocation associated with femoral trochlear dysplasia. The knee with traumatic dislocation at the time of presentation or that had dislocated most frequently was treated with medial patellar retinacular plasty (Group S). The contralateral knee served as a control and was treated conservatively (Group C). All patients were treated between October 2008 and August 2013. The mean follow-up was 48.7 months (43 to 56). Axial CT scans were undertaken in all patients to assess the trochlear morphological characteristics on a particular axial image which was established at the point with the greatest epicondylar width based on measurements preoperatively and at the final follow-up. Results Preoperatively, there were no statistically significant differences between the trochlear morphology in the two groups (sulcus angle, p 0.852; trochlear groove depth, p 0.885; lateral trochlear inclination, p 0.676; lateral-to-medial facet ratio, p 0.468; lateral condylar height, p 0.899; medial condylar height, p 0.816). Many radiological parameters of trochlear morphology were significantly different between the two groups at the final follow-up, including well-known parameters, such as the mean sulcus angle (Group S, 146.27° (sd 7.18); Group C, 160.61° (sd 9.29); p < 0.001), the mean trochlear groove depth (Group S, 6.25 mm (sd 0.41); Group C, 3.48 mm (sd 0.65); p < 0.001) and the mean lateral trochlear inclination (Group S, 20.99° (sd 3.87); Group C, 12.18° (sd 1.85); p < 0.001). Lesser known parameters such as the ratio of the lateral to medial trochlear length (Group S, 1.46 (sd 0.19); Group C, 2.14 (sd 0.42); p < 0.001), which is a measurement of facet asymmetry, and the lateral and medial condylar height were also significantly different between the two groups (p < 0.001). Conclusion The femoral trochlear morphology can be improved by early (before epiphyseal closure) surgical correction in children with recurrent patellar dislocation associated with femoral trochlear dysplasia. Cite this article: Bone Joint J 2018;100-B:811–21.
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Affiliation(s)
- K. Fu
- Department of Orthopaedic Surgery, Hebei
Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - G. Duan
- Department of Orthopaedic Surgery, Hebei
Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - C. Liu
- Department of Orthopaedic Surgery, Hebei
Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - J. Niu
- Department of Orthopaedic Surgery, Hebei
Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - F. Wang
- Department of Orthopaedic Surgery, Hebei
Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
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Biomechanical Analysis of Tibial Tuberosity Medialization and Medial Patellofemoral Ligament Reconstruction. Sports Med Arthrosc Rev 2018; 25:58-63. [PMID: 28459747 DOI: 10.1097/jsa.0000000000000152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Biomechanical studies are commonly performed to evaluate the influence of medial patellofemoral ligament (MPFL) reconstruction and tibial tuberosity medialization on patellar tracking and patellofemoral contact pressures. The most common method is in vitro simulation of knee function, but computational simulation of knee function and computational reconstruction of in vivo motion can also be utilized. The current review of the biomechanical literature indicates that MPFL reconstruction and tibial tuberosity medialization reduce lateral patellar tracking. Decreased lateral patellofemoral contact pressures have also been noted. For MPFL reconstruction, the most commonly noted biomechanical concerns are graft overtensioning and nonanatomic attachment on the femur leading to overconstraint of the patella and elevated medial contact pressures. For tuberosity medialization, the influence of altered tibiofemoral kinematics on postoperative function is unknown. Future biomechanical studies should emphasize inclusion of anatomic features and tracking patterns related to patellar instability, with comparison between the surgical approaches for continued development of treatment guidelines.
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Zhang GY, Zheng L, Shi H, Liu W, Zhang L, Qu SH, Bai ZW, Ding HY. Correlation analysis between injury patterns of medial patellofemoral ligament and vastus medialis obliquus after acute first-time lateral patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2018; 26:719-726. [PMID: 28028571 DOI: 10.1007/s00167-016-4408-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 12/07/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the correlation between injury patterns of the medial patellofemoral ligament (MPFL) and vastus medialis obliquus (VMO) after acute first-time lateral patellar dislocation (LPD) in adults. METHODS Magnetic resonance imaging (MRI) was prospectively performed in 132 consecutive adults with acute first-time LPD. Images were acquired and evaluated using standardized protocols. Injury patterns of MPFL were grouped by location and severity for analysis of the prevalence of VMO injury. RESULTS MRI demonstrated VMO injury in 63 (47.7%) patients. Twenty (38.5%) and 43 cases (56.6%) were present in partial and complete MPFL tear subgroups, respectively. Compared with partial MPFL tears, complete tears showed a higher prevalence of VMO injury (P = 0.044). The mean coronal (28.5 mm) and mean sagittal VMO elevations (20.7 mm) were higher in the complete MPFL tear subgroup than in the partial tear subgroup (19.8 mm, P = 0.005; 11.9 mm, P < 0.001). No correlations were identified between the prevalence of VMO injury and location subgroups of MPFL injury (n.s.). Mean VMO elevations were higher in isolated femoral-side (FEM) and combined MPFL tear (COM) subgroups (mean coronal VMO elevation of 29 mm and mean sagittal VMO elevation of 20.8 mm in the FEM subgroup; mean coronal VMO elevation of 29.6 mm and mean sagittal VMO elevation of 23.1 mm in the COM subgroup) than in the isolated patellar-side MPFL tear (PAT) subgroup (P = 0.022, P < 0.001) (mean coronal VMO elevation of 20.7 mm and mean sagittal VMO elevation of 10.6 mm). CONCLUSIONS Complete MPFL tear predisposes to VMO injury and has a higher elevation of torn VMO after acute first-time LPD in adults. Isolated femoral-side and combined MPFL tears predispose to higher elevation of torn VMO. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Guang-Ying Zhang
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District, Jinan, 250014, China
| | - Lei Zheng
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Force, Jinan, 250014, China
| | - Hao Shi
- Department of Radiology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, 250014, China
| | - Wei Liu
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District, Jinan, 250014, China
| | - Li Zhang
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District, Jinan, 250014, China
| | - Su-Hui Qu
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District, Jinan, 250014, China
| | - Zheng-Wu Bai
- Department of Orthopedics, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, 250014, China
| | - Hong-Yu Ding
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District, Jinan, 250014, China.
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Anatomic patellar instability risk factors in primary lateral patellar dislocations do not predict injury patterns: an MRI-based study. Knee Surg Sports Traumatol Arthrosc 2018; 26:677-684. [PMID: 28246877 DOI: 10.1007/s00167-017-4464-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The primary goal was to describe the injury patterns in a population of primary (first time) lateral patellar dislocators (LPD) to lend clarity to commonly held notions about injury patterns in this population. METHODS A prospective study identifying patients presenting with LPD between 2008 and 2012. Inclusion criteria were a history and physical exam consistent with primary LPD, and an MRI consistent with the diagnosis without other significant ligamentous injury. On MRI, location of cartilage, medial patellofemoral ligament (MPFL) injury, and bone bruising were noted. Severity was categorized as partial or complete for MPFL and cartilage lesions. Anatomic patellar instability risk factors (patella alta, trochlear dysplasia, increased TT-TG, and lateral patella tilt) were recorded and compared to the injury patterns. RESULTS This study involved 157 patients; 107 patients were skeletally mature. Of the 157 patients, 26 had surgery for this injury due to clinician-perceived need for cartilage debridement. MPFL injury severity was complete rupture (N = 69, 44%), partial (N = 67, 43%), and none (N = 19, 13%). MPFL injury location was isolated femoral (N = 16, 10%), isolated patella (N = 26, 17%), isolated mid-substance (0%), multiple locations (N = 95, 61%), and none (N = 20, 13%). Chondral injury location was patella (N = 67, 43%), lateral femoral condyle (N = 11, 7%), multiple locations (N = 53, 34%), and none (N = 26, 17%). A majority (61%) of patellar chondral lesions were at its inferomedial aspect; all medial patellar retinacular partial injuries involved the inferomedial aspect of the patella, consistent with the insertion of the medial patellotibial ligament (MPTL). Skeletally immature patients had a greater risk of isolated patellar MPFL and chondral injury. No clear relationship was found between/across the location and/or severity of bone bruising, MPFL, or chondral injury. CLINICAL RELEVANCE Underlying anatomic patellar instability risk factors defined by MRI, do not predict injury patterns. MPFL and chondral injury, as well as bone bruising, are common following LPD. The medial patellotibial ligament is torn in patellar-based medial retinacular injuries, based on MRI injury location. Skeletal immaturity plays a role in the location of the injury pattern with isolated patellar-based MPFL/chondral injury being more common in the skeletally immature patient. Sex does not appear to be a factor in injury patterns after primary LPD. Knowledge of these injury trends will help focus the clinician in injury evaluation when managing primary patellar dislocations. LEVEL OF EVIDENCE Case series, Level IV.
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Zhang GY, Zhu HX, Li EM, Shi H, Liu W, Zheng L, Bai ZW, Ding HY. The Correlation between the Injury Patterns of the Medial Patellofemoral Ligament in an Acute First-Time Lateral Patellar Dislocation on MR Imaging and the Incidence of a Second-Time Lateral Patellar Dislocation. Korean J Radiol 2018. [PMID: 29520187 PMCID: PMC5840058 DOI: 10.3348/kjr.2018.19.2.292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective To evaluate the correlation between the injury patterns of the medial patellofemoral ligament (MPFL) on magnetic resonance imaging in an acute first-time lateral patellar dislocation (LPD) and incidence of a second-time LPD. Materials and Methods Magnetic resonance images were prospectively analyzed in 147 patients after an acute first-time LPD with identical nonoperative management. The injury patterns of MPFL in acute first-time LPDs were grouped by location and severity for the analysis of the incidence of second-time LPD in a 5-year follow-up. Independent t tests, chi-square tests and Kruskal-Wallis tests were performed as appropriate. Results Forty-six cases (46/147, 31.3%) of second-time LPD were present at the 5-year follow-up. Fourteen (14/62, 22.6%) and 31 cases (31/80, 38.8%) were present in the partial and complete MPFL tear subgroups, respectively. Twenty-five cases (25/65, 38.5%), 11 cases (11/26, 42.3%), and 8 cases (8/47, 17%) were present in the isolated femoral-side MPFL tear (FEM), combined MPFL tear (COM), and isolated patellar-side MPFL tear (PAT) subgroups, respectively. Compared with the partial MPFL tears, complete tears showed higher incidence of a second-time LPD (p = 0.04). The time interval between the two LPDs was shorter in the complete MPFL tear subgroup (24.2 months) than in the partial tear subgroup (36.9 months, p = 0.001). Compared with the PAT subgroup, the FEM and COM subgroups showed a higher incidence of a second-time LPD (p = 0.025). The time intervals between the two LPDs were shorter in the FEM and COM subgroups (20.8 months and 19.2 months) than in the PAT subgroup (32.5 months, p = 0.049). Conclusion A complete MPFL tear, isolated femoral-side tear and combined tear in a first-time LPD predispose a second-time LPD.
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Affiliation(s)
- Guang-Ying Zhang
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
| | - Hong-Xia Zhu
- Department of Ultrasonography, The Second People's Hospital of Liaocheng, Liaocheng 252601, China
| | - En-Miao Li
- Department of Ultrasonography, Jinan Third People's Hospital, Jinan 250132, China
| | - Hao Shi
- Department of Radiology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
| | - Wei Liu
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
| | - Lei Zheng
- Department of Radiology, Shandong Provincial Corps Hospital of Chinese People's Armed Police Force, Jinan 250014, China
| | - Zheng-Wu Bai
- Department of Orthopedics, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
| | - Hong-Yu Ding
- Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
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46
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Aframian A, Smith TO, Tennent TD, Cobb JP, Hing CB. Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc 2017; 25:3755-3772. [PMID: 27631645 PMCID: PMC5698363 DOI: 10.1007/s00167-016-4272-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 01/01/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the major medial soft-tissue stabiliser of the patella, originating from the medial femoral condyle and inserting onto the medial patella. The exact position reported in the literature varies. Understanding the true anatomical origin and insertion of the MPFL is critical to successful reconstruction. The purpose of this systematic review was to determine these locations. METHODS A systematic search of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and Cochrane Library) and unpublished literature databases was conducted from their inception to the 3 February 2016. All papers investigating the anatomy of the MPFL were eligible. Methodological quality was assessed using a modified CASP tool. A narrative analysis approach was adopted to synthesise the findings. RESULTS After screening and review of 2045 papers, a total of 67 studies investigating the relevant anatomy were included. From this, the origin appears to be from an area rather than (as previously reported) a single point on the medial femoral condyle. The weighted average length was 56 mm with an 'hourglass' shape, fanning out at both ligament ends. CONCLUSION The MPFL is an hourglass-shaped structure running from a triangular space between the adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle and inserts onto the superomedial aspect of the patella. Awareness of anatomy is critical for assessment, anatomical repair and successful surgical patellar stabilisation. LEVEL OF EVIDENCE Systematic review of anatomical dissections and imaging studies, Level IV.
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Affiliation(s)
- Arash Aframian
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
- St George's, University of London, London, SW17 0RE, UK.
- Imperial College, London, W6 8RP, UK.
| | - Toby O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - T Duncan Tennent
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
- St George's, University of London, London, SW17 0RE, UK
| | | | - Caroline Blanca Hing
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
- St George's, University of London, London, SW17 0RE, UK
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47
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Alm L, Krause M, Mull C, Frosch KH, Akoto R. Modified adductor sling technique: A surgical therapy for patellar instability in skeletally immature patients. Knee 2017; 24:1282-1288. [PMID: 28867290 DOI: 10.1016/j.knee.2017.08.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/26/2017] [Accepted: 08/10/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Due to open femoral physis the therapy of patellar instability in skeletally immature patients is challenging. We developed a modified surgical technique of the 'Adductor-Sling-Approach' by Sillanpää. The purpose of this study was to evaluate the clinical outcome of the operative technique and to analyse the reasons for failure. METHODS Thirty 'modified adductor sling' reconstructions in 28 patients were included in the study. From 2010 to 2016 modified adductor sling reconstruction was performed by looping the gracilis or semitendinosus tendon around the adductor magnus tendon and attaching it at the medial facet of the patella. Clinical outcome was retrospectively evaluated at a mean follow up of 25.6months (range 12-43). The evaluation also included subjective International Knee Documentation Committee (IKDC), Lysholm Score, Kujala Score and Tegner Activity Score. RESULTS The average age at the time of operation was 15.10years (range 11-17). Eighty-seven percent of the patients, who underwent the modified adductor sling technique, gained a stable patella and excellent results in postoperative scores. Recurrent dislocation occurred in four of 30 cases (13%). Analysis showed that possible reasons for failure of the tendon graft could be maltracking of the patella due to patella alta, trochlear dysplasia or an elevated tibial tuberosity to trochlear groove distance. CONCLUSION The modified adductor sling technique for MPFL reconstruction in children and adolescents showed elevated redislocation rates. Only in absence of additional patellofemoral maltracking, caused by elevated tibial tubercle to trochlear groove distance (>15mm), patella alta or especially severe trochlear dysplasia, the modified adductor sling technique could be recommended.
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Affiliation(s)
- Lena Alm
- Department of Trauma and Reconstructive Surgery with Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Reconstructive Surgery with Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Carolin Mull
- Department of Trauma and Reconstructive Surgery with Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Reconstructive Surgery with Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany.
| | - Ralph Akoto
- Department of Trauma and Reconstructive Surgery with Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany
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Tischer T, Geier A, Lenz R, Woernle C, Bader R. Impact of the patella height on the strain pattern of the medial patellofemoral ligament after reconstruction: a computer model-based study. Knee Surg Sports Traumatol Arthrosc 2017; 25:3123-3133. [PMID: 27289460 DOI: 10.1007/s00167-016-4190-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/31/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction is a key procedure for treating patellofemoral instability. However, controversy exists regarding the correct graft placement in different patellar heights. Therefore, our study aimed to investigate the influence of patellar height on MPFL insertion points. METHODS Strain patterns of the reconstructed MPFL were calculated using a dynamic musculoskeletal multibody simulation. Numerous patellar (proximal, central, distal) and femoral attachment sites (around the radiological point according to Schöttle) were analysed in the presence of different patella heights [Insall-Salvati (IS) indices 0.74, 1.0, 1.5] during dynamic knee flexion from 0° to 120°. RESULTS The reconstructed MPFL showed an almost isometric behaviour at the anatomic insertion (IS 1.0). Slight variation (<5 mm) around the ideal femoral insertion point resulted in only small changes in MPFL tension. However, a displacement of 10 mm led to a significant increase in MPFL tension, especially in the more anteriorly/proximally located femoral attachment points. Depending on the patella height, there exists an area of absolute isometry of the MPFL (length change <3 %) on the femoral condyle, which did not necessarily coincide exactly with the radiological point, but was located within a radius of 5 mm around it. CONCLUSIONS When reconstructed in the radiological femoral insertion point, MPFL strain patterns were only slightly affected by different patella heights (IS 0.74-1.5) suggesting that MPFL reconstruction could be safely performed using the radiological insertion. However, in case of a patella alta (IS 1.5), a slightly more proximal femoral insertion is beneficial for the biomechanical behaviour of the reconstructed MPFL.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany.
| | - Andreas Geier
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
| | - Christoph Woernle
- Chair of Technical Dynamics, University of Rostock, Rostock, Germany
| | - Rainer Bader
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
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Arendt EA, England K, Agel J, Tompkins MA. An analysis of knee anatomic imaging factors associated with primary lateral patellar dislocations. Knee Surg Sports Traumatol Arthrosc 2017; 25:3099-3107. [PMID: 27145773 DOI: 10.1007/s00167-016-4117-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/29/2016] [Indexed: 01/27/2023]
Abstract
PURPOSE Various knee anatomic imaging factors have been historically associated with lateral patellar dislocation. The characterization of these anatomic factors in a primary lateral patellar dislocation population has not been well described. Our purpose was to characterize the spectrum of anatomic factors from slice imaging measurements specific to a population of primary lateral patellar dislocation. A secondary purpose was to stratify these data by sex/skeletal maturity to better detail potential dimorphic characteristics. METHODS Patients with a history of primary lateral patellar dislocation between 2008 and 2012 were prospectively identified. Ten MRI measurements were analysed with results stratified by sex/skeletal maturity. A '4-factor' analysis was performed to detail the number of 'excessive' anatomic factors within a single individual. RESULTS This study involved 157 knees (79 M/78 F), and 107 patients were skeletally mature. The measurements demonstrate more anatomic risk factors in this population than historical controls. Patella height and trochlear measurements are the most common 'dysplastic' anatomic factors in this population. There were differences based on sex for some patellar height measurements and for TT-TG; there were no differences based on skeletal maturity. CONCLUSION Primary lateral patellar dislocation patients have MRI measurements of knee anatomic factors that are generally more dysplastic than the normal population; however, there is a broad spectrum of anatomic features with no pattern predominating. Characterizing knee anatomic imaging factors in the patient with a primary lateral patellar dislocation is a necessary first step in characterizing the (potential) differences between the primary and recurrent patellar dislocation patient. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
| | - Kristin England
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA
| | - Julie Agel
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.,TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN, USA
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50
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Vetrano M, Oliva F, Bisicchia S, Bossa M, De Carli A, Di Lorenzo L, Erroi D, Forte A, Foti C, Frizziero A, Gasparre G, Via AG, Innocenti B, Longo UG, Mahmoud A, Masiero S, Mazza D, Natali S, Notarangelo C, Osti L, Padulo J, Pellicciari L, Perroni F, Piccirilli E, Ramponi C, Salvatore G, Panni AS, Suarez T, Tarantino U, Vittadini F, Vulpiani MC, Ferretti A, Maffulli N. I.S.Mu.L.T. first-time patellar dislocation guidelines. Muscles Ligaments Tendons J 2017; 7:1-10. [PMID: 28717605 DOI: 10.11138/mltj/2017.7.1.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary traumatic patellar dislocation is common, particularly in young active individuals. A consensus on its management is still lacking. The present work provides easily accessible guidelines to be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care and rationalize the use of resources. LEVEL OF EVIDENCE Ia.
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Affiliation(s)
- Mario Vetrano
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Salvatore Bisicchia
- Department of Orthopaedic Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Michela Bossa
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Angelo De Carli
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Di Lorenzo
- Rehabilitation Unit, Neuroscience Department, "RUMMO" Hospital, Benevento, Italy.,Biomedical Research Centre, Gruppo Forte, Salerno, Italy
| | - Davide Erroi
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Alfonso Forte
- Biomedical Research Centre, Gruppo Forte, Salerno, Italy
| | - Calogero Foti
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Giuseppe Gasparre
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Alessio Giai Via
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), École Polytechnique de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Umile Giuseppe Longo
- Department of Orthopedic and Traumatology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Asmaa Mahmoud
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Daniele Mazza
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Simone Natali
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Christian Notarangelo
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Leonardo Osti
- Unit of Arthroscopy and Sports Trauma Surgery, Hesperia Hospital, Modena, Italy
| | - Johnny Padulo
- University eCampus, Novedrate, Italy; Tunisian Research Laboratory "Sports Performance Optimization", National Center of Medicine and Science in Sport, Tunis, Tunisia; Faculty of Kinesiology, University of Split, Split, Croatia
| | - Leonardo Pellicciari
- Department of Physical Medicine and Rehabilitation, University of Rome "Tor Vergata", Rome, Italy
| | - Fabrizio Perroni
- School of Exercise and Sport Sciences (SUISM), Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Piccirilli
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Carlo Ramponi
- Sport Physical Therapist, Kinè Physiotherapic Center, Conegliano, Italy
| | - Giuseppe Salvatore
- Department of Orthopedic and Traumatology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Alfredo Schiavone Panni
- Multidisciplinary Department of Medical-Surgical and Dental Specialty, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Tania Suarez
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Filippo Vittadini
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Maria Chiara Vulpiani
- Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Department and "Kirk Kilgour" Sports Injury Center, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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