1
|
Bernstein M, Bozzo I, Patrick Park J, Pauyo T. Patellofemoral Instability Part II: Surgical Treatment. J Am Acad Orthop Surg 2024; 32:e1035-e1046. [PMID: 38723282 DOI: 10.5435/jaaos-d-23-00650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/25/2024] [Indexed: 10/05/2024] Open
Abstract
Treatment of patellofemoral instability in skeletally mature patients remains an important area of clinical and research interest. Both nonsurgical and surgical interventions are used to treat the underlying causes. Surgical management is the mainstay of treatment of recurrent PFI that fails nonsurgical treatment, and it is broadly classified into bony and soft-tissue procedures. Proximal bony procedures include femoral trochleoplasty, derotational osteotomies, and coronal alignment correction of the femur. Distal bony procedures include tibial tubercle transfer and derotational (supratubercle and infratubercle) osteotomies. Soft-tissue procedures consist of medial patellofemoral ligament repair or reconstruction and lateral lengthening procedures. This article is the second part of our two-article review on PFI, which focuses on surgical treatment options, their indications, outcomes, and potential complications.
Collapse
Affiliation(s)
- Mitchell Bernstein
- From the Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | |
Collapse
|
2
|
Senese M, Smith V. Minimizing Redislocation Rates and Restoring Function After Patella Dislocation: A Critically Appraised Topic. J Sport Rehabil 2024:1-8. [PMID: 39255960 DOI: 10.1123/jsr.2023-0426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 06/12/2024] [Accepted: 07/17/2024] [Indexed: 09/12/2024]
Abstract
CLINICAL SCENARIO Patella dislocation is a common knee injury resulting in decreased function, increased knee pain, and a higher risk of recurrent patella dislocation. Patients with patella instability are treated surgically or conservatively with physical therapy to minimize redislocation risk and restore function. CLINICAL QUESTION In individuals with a patella dislocation, how does treatment (conservative therapy versus medial patellofemoral ligament [MPFL] surgery) affect redislocation rates and patient-perceived function? SUMMARY OF KEY FINDINGS This critically appraised topic included 3 studies assessing outcomes in individuals with patella instability treated with MPFL surgery or conservative management. Outcomes included comparing redislocation rates and Kujala scale perceived knee function between participant groups. Surgery included MPFL reconstruction (MPFL-R) in 1 randomized controlled trial and 1 prospective controlled trial and MPFL repair in another randomized controlled trial. Conservative treatment included physical therapy and bracing. All 3 studies demonstrated significantly lower redislocation rates in individuals managed with surgery versus conservative treatment. Reported knee function was significantly higher in the MPFL-R group compared with individuals conservatively managed at 2-year follow-up but not at 1 year. No significant difference in knee function was present between individuals receiving MPFL repair or conservative management at a 2-year follow-up. CLINICAL BOTTOM LINE There is moderate-level evidence to support a significant decrease in patella redislocation rates in individuals managed with MPFL surgery compared with conservative treatment. The reviewed studies suggest a significant improvement in patient-perceived knee function at 2 years following MPFL-R but no difference at 1 year following MPFL-R or 2 years after MPFL repair. Strength of Recommendations: Grade B evidence supports lower patella redislocation rates with MPFL surgery compared with nonsurgical treatment. Furthermore, this evidence suggests a potential benefit in perceived knee function 2 years after MPFL-R compared with conservative management.
Collapse
Affiliation(s)
- Matthew Senese
- Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Chalfont, PA, USA
| | - Veronika Smith
- Miami Valley Hospital Huber Heights Physical Therapy, Huber Heights, OH, USA
| |
Collapse
|
3
|
Chen Y, Wang Y, Zhan H, Geng B, Xia Y. Management of Patellar Instability: A Network Meta-analysis of Randomized Control Trials: Letter to the Editor. Am J Sports Med 2024; 52:NP6-NP7. [PMID: 38690621 DOI: 10.1177/03635465241242297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
|
4
|
Parikh SN, Schlechter JA, Veerkamp MW, Stacey JD, Gupta R, Pendleton AM, Shea KG, Friel NA, Molony JT, Yaniv M, Rhodes J, Finlayson CJ, Williams BA, Ellington M. Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents. J Pediatr Orthop 2024; 44:e369-e374. [PMID: 38258884 DOI: 10.1097/bpo.0000000000002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.
Collapse
Affiliation(s)
- Shital N Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - John D Stacey
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rajul Gupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Nicole A Friel
- Shriners Hospitals for Children Northern California, Sacramento, CA
| | | | - Moshe Yaniv
- Dana Children's Hospital, Tel Aviv Medical Center, Israel
| | | | | | | | | |
Collapse
|
5
|
Yoon KH, Jeong BO, Hwang SH, Kim JH, Kim YS, Lee HS. MPFL reconstruction with proximal rather than distal femoral tunnel position leads to less favorable short-term results. Orthop Traumatol Surg Res 2024:103816. [PMID: 38246491 DOI: 10.1016/j.otsr.2024.103816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/06/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament (MPFL) reconstruction (MPFLR) between anatomic femoral tunnel positions: proximal (near adductor tubercle [AT]) and distal (near medial epicondyle [ME]). HYPOTHESIS MPFLR with the proximal femoral tunnel position has worse clinical and radiological outcomes than those with the distal femoral tunnel position. PATIENTS AND METHODS Fifty-five patients who underwent isolated MPFLR with proximal or distal femoral tunnels with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative CT images, 28 patients were classified as group AT and the remaining 27 patients were classified as group ME. The International Knee Documentation Committee, Lysholm, Tegner, Kujala scores, and complications were evaluated. Radiologically, the Caton-Deschamps Index (CDI), patellar tilt angle, patellofemoral osteoarthritis (PFOA), patellofemoral cartilage status by the International Cartilage Repair Society (ICRS) grade, bone contusion, and MPFL graft signal intensity were evaluated. RESULTS All clinical scores significantly improved in both groups (p<0.01). No statistically significant difference was noted between the two groups in regards to their preoperative demographic data, postoperative clinical scores, complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, and graft signal intensity). The group AT had worse cartilage status on the medial facet of the patella (p=0.02). The ICRS grade for the medial facet of the patella statistically progressed in group AT compared to group ME (p=0.04) as well. DISCUSSION Both groups showed significantly improved clinical outcomes. However, for the medial facet of the patella, MPFLR with the proximal femoral tunnel position had worse cartilage status and ICRS grade progression than those with the distal femoral tunnel position. LEVEL OF EVIDENCE III; retrospective comparative study.
Collapse
Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Bi O Jeong
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sung Hyun Hwang
- Department of Orthopaedic Surgery, Pohang St. Mary's Hospital, Pohang-si, Gyeongsangbuk-do, Republic of Korea
| | - Jin Hyung Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoon Seok Kim
- Department of Orthopaedic Surgery, Armed Forces Hongcheon Hospital, Hongcheon-gun, Gangwon-do, Republic of Korea
| | - Hee Sung Lee
- Department of Medicine, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, 02453 Seoul, Republic of Korea.
| |
Collapse
|
6
|
Yi Z, Jiang J, Liu J, Ma M, Chen Y, Teng F, Yang A, Liu Z, Geng B, Xia Y, Wu M. Prevalence and Site of Concomitant Osteochondral Injuries in Patients With Acute Lateral Patellar Dislocation: A Systematic Review and Meta-analysis. Orthop J Sports Med 2024; 12:23259671231220904. [PMID: 38274015 PMCID: PMC10809874 DOI: 10.1177/23259671231220904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 01/27/2024] Open
Abstract
Background Osteochondral injuries (OCIs) are common in patients with acute lateral patellar dislocation, which can produce both short- and long-;term adverse effects. However, the pattern of these injuries warrants further analysis, especially in relation to patient age. Purpose To determine the overall prevalence of concomitant OCIs as well as the prevalence differences based on location and age after acute lateral patellar dislocations. Study Design Systematic review; Level of evidence, 4. Methods A comprehensive search of PubMed, Embase, Web of Science, and Cochrane Library was completed from inception to July 20, 2022. All articles reporting the prevalence of OCI were included. The sample characteristics such as age, study design, magnetic resonance imaging diagnostic data, and the number of patients with OCI were extracted. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment. The overall and per-;site injury rates were calculated, and the prevalence was stratified by age-;group (≤16 and >16 years) and compared. Results The systematic review included 39 studies involving 3354 patients. MINORS scores were 11.94 ± 1.98 and 16 ± 3.46 in the noncomparative and comparative studies, respectively. The overall prevalence of bone bruises and OCI was 89.6% (95% CI, 77.4%-97.7%) and 48.8% (95% CI, 39.0%-58.7%), respectively. In both overall and >16-year-old patients, the lateral femoral condyle (LFC) was the most common site of bone bruise (90.5% [95% CI, 84.0%-95.6%] and 91.5% [95% CI, 84.3%-96.9%], respectively); however, the medial patellar bruise was more common in patients ≤16 years (89.2% [95% CI, 82.9%-94.4%]). Among the pooled sites of OCI, the medial patella accounted for the largest proportion (36.9% [95% CI, 28.0%-46.3%]). OCIs were more common in patients >16 years (52.6% [95% CI, 39.4%-65.6%]) than in patients ≤16 years (46.6% [95% CI, 33.2%-60.3%]). Conclusion Bone bruises on the LFC were most prevalent overall and in patients >16 years, whereas bone bruises on the medial patella were more prevalent in patients ≤16 years. OCIs were frequently seen in patients >16 years, with the most common site being the medial patella.
Collapse
Affiliation(s)
- Zhi Yi
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Jin Jiang
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Jinmin Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Ming Ma
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Yi Chen
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Fei Teng
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Ao Yang
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Zhongcheng Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Bin Geng
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopedic Clinical Medical Research Center of Gansu Province, Intelligent Orthopedic Industry Technology Center of Gansu Province, Lanzhou, Gansu, China
| |
Collapse
|
7
|
Chang B, Schenk RJ. The influence of directional preference on lateral patellar dislocation: a case report. J Man Manip Ther 2023; 31:474-481. [PMID: 37553954 PMCID: PMC10642310 DOI: 10.1080/10669817.2023.2242203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 05/10/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND There is little consensus on the conservative management of lateral patellar dislocations (LPD). Mechanical diagnosis and therapy (MDT) is an established classification system in the spinal and extremity population. This case report describes the use of MDT in the management and classification of a patient with LPD. CASE DESCRIPTION The patient was a 20-year-old female with a 3-month history of left knee pain precipitated by a lateral patellar dislocation. The patient described pain and a feeling of instability with standing and walking and limitations in work and recreational activities which involve lifting, squatting, and running. Based on the patient's response to repeated end range knee movements, the patient was found to have a directional preference (DP) for knee extension and instruction in performance of knee extension DP exercises was provided. OUTCOMES The patient's knee examination and subsequent intervention included her responses to repeated end range knee movements. Her knee pain was abolished, and strength, function, and motion were fully restored in five visits. A minimal clinically important difference (MCID) was achieved on the Lower Extremity Functional Scale (LEFS). At discharge, the patient was able to independently manage symptoms and perform all work and recreational activities at a pre-injury level and these improvements were maintained at a 9-month follow-up. DISCUSSION There are various management strategies for lateral patellar dislocation. This case demonstrated the use of classifying, subgrouping, and treating a patient with lateral patellar dislocation using the principle of DP. CONCLUSION The patient's outcomes suggest that MDT may be used in the nonoperative management of people with LPD who present with a DP.
Collapse
Affiliation(s)
- B Chang
- Rusk Rehabilitation, NYU Langone Health New York, New York, USA
| | - RJ Schenk
- Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
8
|
Alshaban RM, Ghaddaf AA, Alghamdi DM, Aghashami A, Alqrni A, Alyasi AA, Bogari H, Qadi S. Operative versus non-operative management of primary patellar dislocation: A systematic review and network meta-analysis. Injury 2023; 54:110926. [PMID: 37473507 DOI: 10.1016/j.injury.2023.110926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Acute patellar dislocation is a common knee injury in adolescents and adults that is associated with a high incidence of medial patellofemoral ligament (MPFL) injuries. The aim of this network meta-analysis was to compare the different operative and non-operative protocols for the management of primary patellar dislocation (PPD). METHODS We searched Medline, Embase, and CENTRAL databases. We included randomized controlled trials (RCTs) that compared operative and non-operative protocols for adolescent or adult patients with acute traumatic PPD. We sought to evaluate the clinical and functional outcomes of each management protocol by considering the results of Kujala score, Tegner activity score, redislocation rate, and subluxation rate. The effectiveness of the different management protocols was measured through frequentist network meta-analysis, using the Netmeta statistical package in R software. All treatment protocols were ranked using the netrank function, yielding P scores. RESULTS A total of 10 RCTs were deemed eligible. As per P-scores, open MPFL repair yielded the highest effectiveness with respect to Kujala score (P=0.81) and lowest odds for redislocation (P=0.14) whereas arthroscopic MPFL repair yielded the highest effectiveness with respect to Tegner activity score (P=0.85) and lowest odds for subluxation (P=0.21). Arthroscopic MPFL repair showed a significant reduction in redislocation and subluxation rate. CONCLUSION This network meta-analysis demonstrated arthroscopic MPFL repair is the most effective treatment protocol for the management of acute primary patellar dislocation.
Collapse
Affiliation(s)
- Raneem M Alshaban
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Dalia M Alghamdi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Afnan Aghashami
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ali Alqrni
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulrahman A Alyasi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan Bogari
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Sara Qadi
- College of Medicine, King Saud bin Abdulaziz University for health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Orthopedic Surgery Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| |
Collapse
|
9
|
Samelis PV, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus 2023; 15:e46743. [PMID: 38021800 PMCID: PMC10631568 DOI: 10.7759/cureus.46743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
Collapse
Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis and Aglaia Kyriakou, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Panagiotis Koulouvaris
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Olga Savvidou
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Andreas Mavrogenis
- Orthopaedics, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Panayiotis J Papagelopoulos
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| |
Collapse
|
10
|
Maggioni DM, Giorgino R, Messina C, Albano D, Peretti GM, Mangiavini L. Framing Patellar Instability: From Diagnosis to the Treatment of the First Episode. J Pers Med 2023; 13:1225. [PMID: 37623475 PMCID: PMC10456090 DOI: 10.3390/jpm13081225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
The patellofemoral joint (PFJ) is a complex articulation between the patella and the femur which is involved in the extensor mechanism of the knee. Patellofemoral disorders can be classified into objective patellar instability, potential patellar instability, and patellofemoral pain syndrome. Anatomical factors such as trochlear dysplasia, patella alta, and the tibial tuberosity-trochlear groove (TT-TG) distance contribute to instability. Patellofemoral instability can result in various types of dislocations, and the frequency of dislocation can be categorized as recurrent, habitual, or permanent. Primary patellar dislocation requires diagnostic framing, including physical examination and imaging. Magnetic resonance imaging (MRI) is essential for assessing the extent of damage, such as bone bruises, osteochondral fractures, and medial patellofemoral ligament (MPFL) rupture. Treatment options for primary dislocation include urgent surgery for osteochondral fragments or conservative treatment for cases without lesions. Follow-up after treatment involves imaging screening and assessing principal and secondary factors of instability. Detecting and addressing these factors is crucial for preventing recurrent dislocations and optimizing patient outcomes.
Collapse
Affiliation(s)
- Davide Maria Maggioni
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20122 Milan, Italy;
| | - Riccardo Giorgino
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20122 Milan, Italy;
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, Via della Commenda 10, 20122 Milan, Italy
| | - Giuseppe Michele Peretti
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Laura Mangiavini
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Sinikumpu J, Nicolaou N. Current concepts in the treatment of first-time patella dislocation in children and adolescents. J Child Orthop 2023; 17:28-33. [PMID: 36755554 PMCID: PMC9900011 DOI: 10.1177/18632521221149060] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023] Open
Abstract
Background Lateral dislocation of the patella is a common injury in children. It can occur in previously healthy and anatomically normal knees, but there are several abnormalities that predispose to patellar instability. Magnetic resonance imaging is an essential part of assessing for associated injuries and risk of further instability. Treatment aims to prevent redislocation, residual instability, osteoarthritis, and allow return to previous activities. The purpose of this review was to assess evidence for management of first-time patella dislocation in children and adolescents. Methods Literature review was performed, accompanied by the current best practice by the authors. Results Non-operative treatment is preferred, except where there are associated injuries such as osteochondral fractures that would benefit from surgery. The exact method of ideal non-operative management is not clearly defined but should focus on restoration of range of movement and strength with bracing as indicated. There seems to be a trend toward operative intervention that may well be inappropriate. Conclusion Further prospective studies are required with focus on the younger patient to fully understand if there is an at-risk group that would benefit from early surgery. Level of evidence level III.
Collapse
Affiliation(s)
- Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopaedics, Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Nicolas Nicolaou
- Department of Paediatric Orthopaedic Surgery, Sheffield Children’s Hospital, Sheffield, UK
| |
Collapse
|
13
|
A 20-Year Retrospective Study of Children and Adolescents Treated by the Three-in-One Procedure for Patellar Realignment. J Clin Med 2023; 12:jcm12020702. [PMID: 36675630 PMCID: PMC9861102 DOI: 10.3390/jcm12020702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Patellar instability is the most common disorder of the knee during childhood and adolescence. Surgical treatment significantly reduces the rate of redislocation, but the underlying pathologies and pattern of instability may affect the results. We aimed to report the clinical and functional outcomes of the three-in-one procedure for patellar realignment in a cohort of skeletally immature patients with or without syndromes and various patterns of chronic patellar instability. METHODS We retrospectively investigated 126 skeletally immature patients (168 knees) affected by idiopathic or syndromic patellar instability, who underwent patella realignment through a three-in-one procedure. We classified the instability according to the score proposed by Parikh and Lykissas. RESULTS Patellar dislocation was idiopathic in 71 patients (94 knees; 56.0%) and syndromic in 55 (74 knees; 44.0%). The mean age at surgery was 11.5 years (range 4-18) and was significantly lower in syndromic patients. Syndromic patients also exhibited more severe clinical pattern at presentation, based on the Parikh and Lykissas score. The mean follow-up was 5.3 years (range 1.0-15.4). Redislocation occurred in 19 cases, with 10 cases requiring further realignment. The Parikh and Lykissas score and the presence of congenital ligamentous laxity were independent predictors of failure. A total of 22 knees in 18 patients required additional surgical procedures. The post-operative Kujala score was significantly lower in patients with syndromic patellar instability. CONCLUSIONS The type of instability and the presence of underlying syndromes negatively affect the rate of redislocation and the clinical and functional outcome following patellar realignment through the three-in-one procedure. We recommend the consideration of alternative surgical strategies, especially in children with severe syndromic patellar dislocation.
Collapse
|
14
|
Parikh SN, Veerkamp M, Redler LH, Schlechter J, Williams BA, Yaniv M, Friel N, Perea SH, Shannon SR, Green DW. Patellar Instability in Young Athletes. Clin Sports Med 2022; 41:627-651. [DOI: 10.1016/j.csm.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
15
|
Kolb A, Willegger M, Chiari C, Windhager R. Behandlung der Patellainstabilität. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:463-475. [PMID: 33851401 DOI: 10.1055/a-1295-0533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
16
|
Watson R, Sullivan B, Stone AV, Jacobs C, Malone T, Heebner N, Noehren B. Lateral Patellar Dislocation: A Critical Review and Update of Evidence-Based Rehabilitation Practice Guidelines and Expected Outcomes. JBJS Rev 2022; 10:01874474-202205000-00004. [PMID: 35748823 DOI: 10.2106/jbjs.rvw.21.00159] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Nonoperative treatment of a lateral patellar dislocation produces favorable functional results, but as high as 35% of individuals experience recurrent dislocations. » Medial patellofemoral ligament reconstruction is an effective treatment to prevent recurrent dislocations and yield excellent outcomes with a high rate of return to sport. » Both nonoperative and postoperative rehabilitation should center on resolving pain and edema, restoring motion, and incorporating isolated and multijoint progressive strengthening exercises targeting the hip and knee. » Prior to return to sports, both functional and isolated knee strength measurements should be used to determine leg symmetry strength and to utilize patient-reported outcome measures to assess the patient's perceived physical abilities and patellofemoral joint stability.
Collapse
Affiliation(s)
- Richard Watson
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky
| | - Breanna Sullivan
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Austin V Stone
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Cale Jacobs
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Terry Malone
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky
| | - Nicholas Heebner
- Department of Athletic Training, University of Kentucky, Lexington, Kentucky
| | - Brian Noehren
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
17
|
Camanho GL, Gobbi RG, Andrade MHD. Complicações funcionais do tratamento da instabilidade patelar com reconstrução do ligamento femoropatelar medial com terço medial do tendão patelar com acompanhamento mínimo de 5 anos. Rev Bras Ortop 2021; 57:308-313. [PMID: 35652011 PMCID: PMC9142260 DOI: 10.1055/s-0041-1729570] [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: 05/25/2020] [Accepted: 11/03/2020] [Indexed: 10/24/2022] Open
Abstract
Resumo
Objetivo Avaliar complicações maiores após um mínimo de 5 anos de acompanhamento após luxação aguda ou recidivante da patela tratada com reconstrução do ligamento femoropatelar medial (LFPM) com terço medial do tendão patelar, com ou sem medialização da tuberosidade anterior da tíbia (TAT) associada.
Métodos Um total de 50 pacientes foram incluídos, com acompanhamento mínimo de 5 anos. Os pacientes foram avaliados em relação à ocorrência de complicações como rigidez articular, recidiva de luxação patelar ou instabilidade subjetiva relatada pelos pacientes, e incapacidade de retorno ao nível prévio de atividades físicas.
Resultados O acompanhamento médio foi de 8,9 ± 2,6 anos, com mínimo de 6 e máximo de 15 anos; 64% dos pacientes eram mulheres, com média de idade de 27 ± 11,2 anos; 24% dos pacientes foram submetidos a osteotomia da TAT para medialização concomitantemente; e 46% eram casos agudos. Foram constatados apenas 9 maus resultados (18%), todos decorrentes de recidiva da luxação (12%) e de queixa de instabilidade subjetiva (6%), ocorridos entre 36 e 60 meses de acompanhamento. Não ocorreram outras complicações. Dentre os maus resultados, cinco ocorreram em casos de luxação aguda, e quatro em casos recidivantes, e apenas um havia sido submetido a osteotomia da TAT.
Conclusão A reconstrução do LFPM com terço medial do tendão patelar, associada ou não à osteotomia de medialização da TAT, é uma alternativa no tratamento da instabilidade patelar aguda ou crônica, com falha de apenas 18% em acompanhamento mínimo de 5 anos. Além disso, é um tratamento seguro, sem apresentar outras complicações.
Collapse
Affiliation(s)
- Gilberto Luis Camanho
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | |
Collapse
|
18
|
Objectively quantified lower limb strength recovery in people treated surgically or non-surgically after patellar dislocation: A systematic review. Phys Ther Sport 2021; 51:110-138. [PMID: 34325188 DOI: 10.1016/j.ptsp.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 05/12/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Synthesize evidence on objectively quantified lower limb strength recovery in people treated surgically or non-surgically after patellar dislocation. METHODS MEDLINE, EMBASE, Cochrane Library, SPORTDiscus, PEDro, AMED and CINAHL databases were last searched on July 30th, 2020 for randomized controlled trials and observational studies that objectively quantified lower limb strength in people (any age or sex) treated surgically or non-surgically after patellar dislocation. RESULTS 24 studies were included (877 participants, median age 20.7). All assessed knee extension strength, 11 knee flexion strength, three hip abduction strength, two hip external rotation strength, and one hip flexion, extension, adduction, and internal rotation strength. One randomized controlled trial judged at high risk of bias and two cohort studies with methodological limitations compared lower limb strength recovery between surgically and non-surgically treated people, with conflicting findings. After surgery, median long-term (>8 months) knee extension strength was 82.5% (IQR 78.5-88.2; 13 studies) of the unaffected leg and knee flexion strength was 91.5% (IQR 90.7-96.9; five studies). After non-surgical treatment, median long-term knee extension strength was 86% (IQR 79.3-87.4; four studies) and mean flexion strength ranged from 95.2 to 96.7% (two studies). Mean hip strength was always >90% (two studies). Two redislocations during eccentric isokinetic knee testing and knee pain during isokinetic knee extension testing were reported as adverse events. CONCLUSIONS Available evidence indicates that after patellar dislocation, knee extension strength deficits in the affected limb are frequently observed and can persist long term, but this remains uncertain due to the limitations of relevant included studies. Whether lower limb strength recovery differs between people treated surgically and those treated non-surgically after patellar dislocation also remains uncertain. TRIAL REGISTRATION (PROSPERO CRD42019139533).
Collapse
|
19
|
Rund JM, Hinckel BB, Sherman SL. Acute Patellofemoral Dislocation: Controversial Decision-Making. Curr Rev Musculoskelet Med 2021; 14:82-87. [PMID: 33523411 DOI: 10.1007/s12178-020-09687-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW The topic of acute patella dislocations is controversial. Discussions revolve around which individuals need early surgery, identification of risk factors, and rehabilitation protocol. The purpose of this review is to discuss the current recommendations for non-operative and/or operative management of first-time dislocators. RECENT FINDINGS Recent studies have made it clear that not all patellar dislocations are the same, not all patients do well with conservative treatment, and risk stratification can identify individuals at high risk of recurrence who would benefit from early surgical intervention. Risk factors that have been identified include younger age, skeletally immature, contralateral instability, trochlear dysplasia, patella alta, increased tibial tubercle-trochlear groove distance, and increased patella tilt. The PAPI (Pediatric and Adolescent Patellar Instability) RCT study and JUPITER (Justifying Patellar Instability Treatment by Early Results) prospective cohort study have been carefully developed, are under way, and will provide further guidance. In summary, the management of acute patellar dislocations is evolving. Surgery for patients with osteochondral loose bodies should include fixation as well as soft tissue stabilization. The standard of care for patients with an acute patellar dislocation without osteochondral loose bodies or fracture is non-operative treatment. However, imaging for all first-time dislocators is indicated to stratify risks and determine risk profile. If an individual is at high risk, soft tissue stabilization may be considered. Still, most patients will be treated non-operatively.
Collapse
Affiliation(s)
- Joseph M Rund
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Betina B Hinckel
- Oakland University, Rochester, MI, USA
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA, USA.
- , Redwood City, USA.
| |
Collapse
|
20
|
Martinez-Cano JP, Chica J, Martinez-Arboleda JJ, Rincón-Escobar E, Zamudio-Castilla L, Renjifo M, Martinez-Rondanelli A. Patellofemoral Dislocation Recurrence After a First Episode: A Case-Control Study. Orthop J Sports Med 2021; 9:2325967120981636. [PMID: 33614800 PMCID: PMC7869156 DOI: 10.1177/2325967120981636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/19/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Lateral patellar dislocation can become a recurrent problem after the first
episode. Identifying those patients who are at increased risk of
redislocation is important for the treatment decision-making process. Purpose: To identify clinical and radiologic risk factors for recurrence of patellar
dislocation after a first episode. Study Design: Case-control study; Level of evidence, 3. Methods: The study included patients with lateral patellar dislocation and a 1-year
minimum follow-up who were seen between 2011 and 2018. Patients aged 10 to
65 years were included. Patient characteristics, physical examination
(patellar apprehension, J sign), and radiographs were reviewed. The
Caton-Deschamps and Insall-Salvati ratios were used to evaluate patella
alta. High-grade trochlear dysplasia was defined as Dejour types B, C, and
D. Results: A total of 130 patients (139 knees) with primary lateral patellar dislocation
were included. Recurrent dislocation was seen in 83 knees (59.71%). Stepwise
logistic regression analysis demonstrated that Caton-Deschamps ratio ≥1.15
(OR, 2.39; 95% CI, 1.09-5.22; P = .029), age <21 years
(OR, 2.53; 95% CI, 1.11-5.77; P = .027), and high-grade
trochlear dysplasia (OR, 4.17; 95% CI, 1.90-9.17; P <
.001) were significantly associated with patellar redislocation. Based on
the presence of these factors, the probability of dislocation after a first
lateral patellar dislocation was 31.2% with no factors present, 36.6% with
any 1 factor present, 71.7% with any 2 factors present, and 86.2% if all 3
conditions were present. Conclusion: The results of this study indicated that patella alta, high-grade trochlear
dysplasia, and age <21 years were independent risk factors for patellar
redislocation after a first episode, with an additive effect when they were
present together. This may help to guide the type of treatment for these
patients.
Collapse
|
21
|
Long-term results of arthroscopic medial reefing for patellar instability. Knee 2020; 27:1182-1189. [PMID: 32711880 DOI: 10.1016/j.knee.2020.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 04/17/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of the study was to investigate the long-term outcomes of the all-inside arthroscopic medial reefing (AAMR) procedure for patellar instability and the factors that affect successful outcome. METHODS In this retrospective study, AAMR with suture was performed in 16 knees of 15 patients who had at least one patellar dislocation and did not experience a decrease in pain and who did not have a major radiological bony abnormality. Preoperatively, Tegner and Lysholm scales were used; for the final evaluation Tegner, Lysholm, Kujala and Knee injury and Osteoarthritis Outcome Score (KOOS) were used. RESULTS The average age of the patients at the time of operation was 18 years (range: 11-36 years). The average follow-up time was 118.3 months (range: 85-143 months). Six of the 16 knees (37.5%) exhibited re-dislocation. Preoperatively, the mean Lysholm and Tegner were 66.5 and 4.0, respectively; and postoperatively increased to 89.3 (P = .001) and 4.66, respectively. At the final follow-up, mean Kujala was 89.3 (good), and mean KOOS was 91.4. In all patients with re-dislocation, fewer than four knots were used, and none of the patients with four knots exhibited re-dislocation. Re-dislocations occurred in two, two, one and one patients at two, three, five and eight years, respectively. CONCLUSIONS The AAMR technique is associated with minimal incisional scarring and an increase in functional scores. It is also associated with a high risk of re-dislocation compared with other methods. If the technique still needs to be used, despite the high re-dislocation rate, at least four knots should be applied.
Collapse
|
22
|
Regarding "Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population". Arthroscopy 2020; 36:1495-1496. [PMID: 32503765 DOI: 10.1016/j.arthro.2020.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
|
23
|
Puzzitiello RN, Agarwalla A, Waterman BR, Verma N, Cole BJ, Yanke A, Forsythe B. Author Reply to "Regarding "Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population". Arthroscopy 2020; 36:1496-1499. [PMID: 32503766 DOI: 10.1016/j.arthro.2020.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam Yanke
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian Forsythe
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| |
Collapse
|
24
|
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).
Collapse
|
25
|
Affiliation(s)
- Christopher Y Kweon
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | | | | |
Collapse
|
26
|
Brand JC, Rossi MJ, Lubowitz JH. Arthroscopy Annual Awards, a 35th Anniversary…and More. Arthroscopy 2020; 36:1-6. [PMID: 31864560 DOI: 10.1016/j.arthro.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 11/03/2019] [Indexed: 02/02/2023]
Abstract
With sincere appreciation to the Arthroscopy Association of North America Education Foundation for their generous support, we announce our 2020 Annual Awards for the best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2019, as well as the Most Downloaded and Most Cited papers published 5 years ago. Our January cover is a throwback in honor of the 35th anniversary of our journal, and our cover will sport a festive banner each month this year. We introduce our 2020 masthead and team, including a new Social Media Board. Finally, our Editor-in-chief, Assistant Editors, and Associate Editors update their disclosures of potential conflicts of interest.
Collapse
|
27
|
Johnson DS, Turner PG. Management of the first-time lateral patellar dislocation. Knee 2019; 26:1161-1165. [PMID: 31727430 DOI: 10.1016/j.knee.2019.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/20/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Little guidance exists on the management of the first-time patellar dislocation. The aim of this article was to review current guidance for management of this condition. METHODS Recent meta-analyses, systematic reviews and current consensus documents relating to first-time patellar dislocation were sourced. An instructional lecture was then created and delivered at the acute knee injuries session at the British Orthopaedic Association 2019 annual conference, which was presented on behalf of the British Association for Surgery of the Knee. This article has been written based on this lecture. RESULTS There is a paucity of literature relating to management of the first-time patellar dislocation. Many studies are of poor design, with inadequate follow-up, making it difficult to draw conclusions from them. However, based upon available information and consensus from working groups it is recommended that patients presenting with first-time dislocation should be assessed to ensure they have not sustained an alternative or associated injury that may require surgical intervention, be assessed and counselled for the risk of recurrent dislocation, and be referred for initial conservative treatment. Surgical stabilisation should be reserved for patients with recurrent instability. CONCLUSIONS Most patients with a first-time patellar dislocation can be managed conservatively, having excluded associated injuries. Due to the poor quality of the literature, care must be taken interpreting the results of studies. It is clear that further research is required in this field.
Collapse
Affiliation(s)
- David Sands Johnson
- Department of Trauma and Orthopaedics, Stockport NHS Foundation Trust, Aspen House, Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, United Kingdom of Great Britain and Northern Ireland; School of Health and Society, Mary Seacole Building, University of Salford, Frederick Road Campus, Salford M6 6PU, United Kingdom of Great Britain and Northern Ireland.
| | - Philip Gartside Turner
- Department of Trauma and Orthopaedics, Stockport NHS Foundation Trust, Aspen House, Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, United Kingdom of Great Britain and Northern Ireland; School of Health and Society, Mary Seacole Building, University of Salford, Frederick Road Campus, Salford M6 6PU, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
28
|
Sherman SL. Editorial Commentary: Risk Stratification Is the New "Standard of Care" Following First-Time Patellar Dislocation. Arthroscopy 2019; 35:2482-2483. [PMID: 31395190 DOI: 10.1016/j.arthro.2019.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 02/02/2023]
Abstract
The standard of care for a first-time patellar dislocation without loose bodies or osteochondral fracture has been nonoperative treatment. However, studies that show high recurrent instability rates and low levels of return to unlimited activity have opened the door to consider early surgical stabilization in high-risk individuals. Risk stratification models have been developed to identify those at highest risk of recurrent dislocation. Although the decision to operate on patients with a first-time dislocation remains controversial, surgeons should at the very least use readily available information to counsel patients regarding their relative risk of recurrence.
Collapse
|