Medial Patellofemoral Ligament Repair or Medial Advancement: Is There a Role?

A modified Delphi consensus statement on patellar instability: part I

Aims

The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

Methods

A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous.

Results

Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus.

Conclusion

The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

Adductor Canal Block Combined with General Analgesia for Patients with Recurrent Patellar Dislocation Undergoing "3-in-1" Procedure Surgery: A Prospective Randomized Controlled Trial

OBJECTIVE

Patellar dislocation is a common injury in sports medicine. While surgical treatment is an important option, pain is severe after surgery. This study compared the analgesic effect and early rehabilitation quality between adductor canal block combined with general analgesia (ACB + GA) and single general analgesia (SGA) after recurrent patellar dislocation (RPD) for "3-in-1" procedure surgery.

METHODS

From July 2018 to January 2020, a prospective randomized controlled trial was conducted in analgesia management after RPD for "3-in-1" procedure surgery. The 40 patients in the experimental group received ACB (0.3% ropivacaine 30 mL) + GA, while the 38 patients in the control group received SGA. Patients in both groups received "3-in-1" procedure surgery, standardized anesthesia, and analgesia during hospitalization. The outcomes included the visual analog scale (VAS), quadriceps strength, Inpatient Satisfaction Questionnaire (IPSQ), Lysholm scores, and Kujala scores. Total rescue analgesic consumption and adverse events were also recorded. One-way analysis of variance (ANOVA) was used to compare continuous variables between groups and chi-square or Fisher's exact tests were used to compare count data. Nonparametric Kruskal-Wallis H tests evaluated ranked data.

RESULTS

No significant differences in resting VAS scores were observed at 8, 12, and 24 h postoperatively. However, the flexion and moving VAS scores of the ACB + GA group were significantly lower than those of the SGA group (p < 0.05). Meanwhile, the first triggering of rescue analgesics was advanced in the SGA group (p < 0.0001), and the dose of opioid analgesics was significantly higher (p < 0.0001). The quadriceps strength of the ACB + GA group was higher than that of the SGA group at 8 h postoperatively. The IPSQ of the ACB + GA group was significantly higher 24 h postoperatively. We observed no significant differences in Lysholm and Kujala scores between the two groups at 3 months after surgery.

CONCLUSIONS

Early analgesia management of ACB + GA showed excellent analgesia effectiveness and a positive hospitalization experience for RPD patients undergoing "3-in-1" procedure surgery. Moreover, this management was good for early rehabilitation.

A 20-Year Retrospective Study of Children and Adolescents Treated by the Three-in-One Procedure for Patellar Realignment

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.

All-arthroscopic Knee Patellofemoral Ligament Repair

Patellar dislocations are common injuries in the pediatric and adolescent population, with an estimated mean incidence of 42/100,000 person-years. The medial patellofemoral ligament is the most important structure preventing lateral patellar translation, whereas its patellar attachment is frequently damaged after patellar dislocations. This technical note presents an all-arthroscopic medial patellofemoral ligament repair technique suggested after a first episode of patellar dislocation.