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Abbaszadeh A, Saeedi M, Hoveidaei AH, Dadgostar H, Razi S, Razi M. Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in recurrent patellar instability: A systematic review and meta-analysis. World J Clin Cases 2023; 11:4625-4634. [PMID: 37469731 PMCID: PMC10353511 DOI: 10.12998/wjcc.v11.i19.4625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/08/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL), along with the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament, aid in the stabilization of the patellofemoral joint. Although the MPFL is the primary stabilizer and the MPTL is a secondary limiter, this ligament is critical in maintaining joint stability. There have been few studies on the combined MPFL and MPTL reconstruction and its benefits.
AIM To look into the outcomes of combined MPFL and MPTL reconstruction in frequent patellar instability.
METHODS By May 8, 2022, four electronic databases were searched: Medline (PubMed), Scopus, Web of Science, and Google Scholar. General keywords such as "patellar instability," "patellar dislocation," "MPFL," "medial patellofemoral ligament," "MPTL," and "medial patellotibial ligament" were co-searched to increase the sensitivity of the search.
RESULTS The pooled effects of combined MPFL and MPTL reconstruction for Kujala score (12-mo follow-up) and Kujala score (24-mo follow-up) were positive and incremental, according to the findings of this meta-analysis. The mean difference between the Cincinnati scores was also positive, but not statistically significant. The combination of the two surgeries reduces pain. According to cumulative meta-analysis, the trend of pain reduction in various studies is declining over time.
CONCLUSION The combined MPFL and MPTL reconstruction has good clinical results in knee function and, in addition to providing good control to maintain patellofemoral joint balance, the patient's pain level decreases over time, making it a valid surgical method for patella stabilization.
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Affiliation(s)
- Ahmad Abbaszadeh
- Department of Orthopedic, Emam Khomeini Teaching Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6135715794, Iran
| | - Mohsen Saeedi
- Department of Orthopedic, Emam Khomeini Teaching Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6135715794, Iran
| | - Amir Human Hoveidaei
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran 14395-578, Iran
| | - Haleh Dadgostar
- Department of Sports and Exercise Medicine, School of Medicine, Rasool Akram Medical Complex, Iran University of Medical Sciences, Tehran 1445613131, Iran
| | - Saeed Razi
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran 1545913487, Iran
| | - Mohammad Razi
- Department of Orthopedic Surgery, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran 1445613131, Iran
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Migliorini F, Maffulli N, Söllner S, Pasurka M, Kubach J, Bell A, Betsch M. Allografts for Medial Patellofemoral Ligament (MPFL) Reconstruction in Adolescent Patients with Recurrent Patellofemoral Instability: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050840. [PMID: 37238388 DOI: 10.3390/children10050840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
This systematic review updates the currently available evidence on medial patella-femoral ligament (MPFL) reconstruction using allografts. The outcomes were measured with patient-reported outcome measures (PROMs), redislocation and complication rates. This study was performed according to the 2020 PRISMA guidelines using the PubMed, Scopus, Web of Science databases, accessed in February 2023. Studies examining the clinical outcomes of MPFL reconstruction with allografts in adolescents and children with recurrent patellofemoral instability (PFI) were included. Data from three trials, including 113 surgical procedures in 121 children, were retrieved. 40% (48/121) of the included patients were girls. The mean age of the patients was 14.7 ± 0.8 years, and the mean follow-up length was 38.1 ± 16.5 months. With MPFL allograft reconstruction, the Kujala score improved by 14.7% (p < 0.0001) and the IKDC by 38.8% (p < 0.0001). The rate of dislocations was 5% (6 of 121), reoperation for instability was 11% (13 of 121), and subluxation was 2% (1 of 47). Conclusion: These results encourage the use of allografts for MPFL reconstruction in adolescent patients with recurrent patellofemoral instability. Though patellofemoral instability is common in clinical practice, the current literature lacks clinical evidence on allograft MPFL reconstruction. Additional high-quality investigations are required to properly establish the long-term advantages of allograft MPFL and its complication rate.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke-on-Trent ST4 7QB, UK
- Barts and The London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London E1 4DG, UK
| | - Stefan Söllner
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Mario Pasurka
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Joshua Kubach
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
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Zhou K, Bai P, Sun Z, Jia Y, Wang F, Wang X, Niu Y. Distalization of tibial tubercle osteotomy is not necessary for patients with recurrent patellar dislocation accompanied by patella alta and increased TT-TG distance. BMC Musculoskelet Disord 2022; 23:838. [PMID: 36057569 PMCID: PMC9440549 DOI: 10.1186/s12891-022-05779-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study is to determine whether distalization of the tibial tubercle is necessary for patients with recurrent patellar dislocation accompanied by patella alta and increased TT-TG. Methods In this retrospective study, all 70 patients (70 knees) with recurrent patellar dislocation accompanied by TT–TG distance ≥20 mm and patella alta (CD-I ≥ 1.4) were surgically treated using MPFLR combined with medialization of the tibial tubercle or medialization and distalization of the tibial tubercle in the Third Hospital of Hebei Medical University between 2017 and 2019. 33 patients(33 knees) received MPFLR combined with medialization of the tibial tubercle (MPFLR + TTm group), 37 patients(37 knees) received MPFLR combined with medialization and distalization of the tibial tubercle (MPFLR + TTm-d group). Evaluation indicators included knee injury and osteoarthritis prognostic score (KOOS) and Kujala score evaluation, congruence angle (CA), patellar tilt angle (PTA), TT-TG distance, Blackburne-Peel index (BP-I), Caton-Deschamps index (CD-I). Results A total of 70 knees (70 patients) with a mean follow-up time of 32 ± 6 months were evaluated in the present study. The postoperative, the PTA, CA, CD-I, BP-I, and TT-TG distance significantly improved in the two groups (P < 0.05), and there was no statistical difference between the two groups (>0.05). The KOOS and Kujala scores of the two groups at the last follow-up were significantly higher than the preoperative scores (P < 0.05), and there was no statistical difference between the two groups (P>0.05). No complications were noted in either group. Conclusion For patients with recurrent patellar dislocation accompanied by increased TT-TG distance and patella alta, distalization is not needed and medialization is sufficient even in the presence of patella alta.
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Affiliation(s)
- Kezhen Zhou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Pengchen Bai
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Zhiwen Sun
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yanfeng Jia
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xiaofeng Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Migliorini F, Eschweiler J, Spiezia F, Knobe M, Hildebrand F, Maffulli N. Synthetic graft for medial patellofemoral ligament reconstruction: a systematic review. J Orthop Traumatol 2022; 23:41. [PMID: 35996063 PMCID: PMC9395552 DOI: 10.1186/s10195-022-00660-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background This systematic review investigates the role of synthetic graft for primary medial patellofemoral ligament (MPFL) reconstruction in patients with recurrent patellofemoral instability, focusing on clinical scores and the rate of complications. Methods This systematic review was conducted according to the PRISMA statement. The main online databases were accessed in January 2022 without time constraints. All clinical studies investigating the use of synthetic grafts for MPFL reconstruction were accessed. Revision settings were not considered. Only articles reporting data on patients with recurrent patellofemoral instability were eligible. Studies regarding congenital or acute patellofemoral dislocation were excluded. Only studies performing a follow-up longer than 24 months were considered. Results Data on 199 patients [mean age 22.3 (range 19.0–28.0) years] were collected. The mean follow-up was 60.5 (39.0–142.8) months. All the scores of interest improved at last follow-up: Kujala (+ 24.8; P = 0.0002), Lysholm (+ 42.0; P = 0.02), Tegner (+ 1.2; P = 0.03), IKDC (+ 20.9; P = 0.02). Post-operatively, a positive apprehension test was detected in 6.1% (7/115) of patients, and a sensation of instability was reported by 1.5% (3/199) of patients. The rate of re-dislocations was 2.5% (5 of 199 patients), and revision procedures were performed in less than 1% (1 of 199) of patients. Conclusion Synthetic graft may be reliable and feasible for primary MPFL reconstruction in patients with recurrent patellofemoral instability.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Spiezia
- Department of Orthopaedic and Trauma Surgery, San Carlo Hospital, Potenza, Italy
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital, 6000, Lucerne, Switzerland
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
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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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Bartsch A, Nüesch C, Rieger B, Mündermann A, Egloff C. Dynamic versus static medial patellofemoral ligament reconstruction technique in the treatment of recurrent patellar dislocation: a randomized clinical trial protocol. J Orthop Surg Res 2022; 17:345. [PMID: 35818060 PMCID: PMC9275045 DOI: 10.1186/s13018-022-03158-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The redislocation rate of conservatively treated patella instability is high. One of the leading surgical strategies is medial patellofemoral ligament reconstruction. Over-tensioning is one of the most challenging complications in static medial patellofemoral ligament reconstruction as the graft used for reconstruction is isometric and the anatomical MPFL is a mostly dynamic structure. As an alternative to established static reconstruction techniques, dynamic graft techniques have been introduced for stabilizing the patella with the aim of providing a more physiological reconstruction of the medial patellofemoral ligament. To date, data on clinical outcomes are scarce and on biomechanical outcomes of the dynamic MPFL reconstruction are lacking. Here, we present the protocol of a randomized clinical trial for comparing clinical and biomechanical outcomes of dynamic versus static medial patellofemoral ligament reconstruction. METHODS This study is a prospective, single blinded, randomized, multicenter, multimodal (clinical and biomechanical) clinical trial. Patients with recurrent patella dislocation requiring isolated MPFL reconstruction will be recruited and randomized to the dynamic or static reconstruction technique. Participants will be followed up for 2 years with a total of five follow-ups. Preoperative magnetic resonance imaging, upright radiographs, surgical reports and patient records will be evaluated, and clinical and functional outcomes will be measured. Patient-reported knee function and anterior knee pain as assessed with the Kujala score will serve as primary outcome. For biomechanical outcome, pre- and postoperative evaluations will be performed to assess isokinetic muscle strength, gait asymmetry, joint kinematics and kinetics, and timing of muscle activity. DISCUSSION The results of the study will clarify whether the reported surgery success for patella stabilization via dynamic MPFL reconstruction is due to muscle contraction or to the passive tenodesis effect combined with clinical outcome measures. With this study, we will provide much needed information on knee biomechanics after dynamic versus static MPFL reconstruction to provide evidence to support orthopedic surgeons in evidence-based decision-making in their quest for surgical techniques most favorable for their patients. Trial registration The study protocol was registered at clinicaltrials.gov (NCT04849130). Registered 19 April 2021, https://clinicaltrials.gov/ct2/show/NCT04849130 .
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Affiliation(s)
- Anna Bartsch
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Corina Nüesch
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Department of Biomedical Engineering, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
| | - Bertram Rieger
- Orthopedic Surgery and Sportsmedicine, ALTIUS Swiss Sportmed Center, Rheinfelden, Switzerland
| | - Annegret Mündermann
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Department of Biomedical Engineering, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
| | - Christian Egloff
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Department of Clinical Research, University of Basel, Basel, Switzerland.
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Migliorini F, Trivellas A, Eschweiler J, Knobe M, Tingart M, Maffulli N. Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:1282-1291. [PMID: 33861358 PMCID: PMC9007784 DOI: 10.1007/s00167-021-06569-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/06/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. METHODS The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. RESULTS Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15-78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). CONCLUSION Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England, UK
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Marín Fermín T, Migliorini F, Kalifis G, Zikria BA, D'Hooghe P, Al-Khelaifi K, Papakostas ET, Maffulli N. Hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective. J Orthop Surg Res 2022; 17:121. [PMID: 35193641 PMCID: PMC8864882 DOI: 10.1186/s13018-022-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This systematic review evaluated the clinical outcomes of hardware-free MPFL reconstruction techniques in patients with recurrent patellofemoral instability, focusing on patient-reported outcome measures (PROMs), redislocation rate, and complications. The hypothesis was that hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective. METHODS This systematic review was conducted following the PRISMA guidelines. PubMed, Scopus, and Virtual Health Library databases were accessed in October 2021. All the clinical studies investigating the efficacy and feasibility of hardware-free MPFL reconstruction were screened for inclusion. Only studies with a minimum 24-month follow-up were considered eligible. Kujala Anterior Knee Pain Scale improvement and redislocation rate after surgical treatment were evaluated as primary outcomes. The rate of postoperative complications was evaluated as a secondary outcome. The quality of the methodological assessment was assessed using the Modified Coleman Methodology Score. RESULTS Eight studies were included in the present systematic review. The quality of the methodological assessment was moderate. Short- to long-term improvement of Kujala score was observed in all included studies. Mean score improvement ranged from + 13.2/100 to + 54/100, with mean postoperative scores ranging from 82/100 to 94/100. Patellar redislocation was observed in 8.33% (8 of 96) patients. CONCLUSION Hardware-free MPFL reconstruction with or without associated soft-tissue or bony realignment procedures provided reliable clinical improvements and was associated with a low rate of redislocation in patients with recurrent patellofemoral instability. Advantages such as safety, femoral physis preservation, and comparable complication profiles with implant-based techniques endorse its implementation. Orthopedic surgeons in cost-sensitive environments may also benefit their patients with lower costs, no need for implants, lack of implant-related complications, or surgery for implant removal. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Giorgos Kalifis
- Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, UK
| | | | - Pieter D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | | | | | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, England.,Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, England
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Kamalapathy P, K Rush J, Montgomery SR, Diduch DR, Werner BC. A National Perspective of Patellar Instability in Children and Adolescents in the United States: MPFL Reconstruction Is Three Times Higher Than the Incidence of Isolated Lateral Release. Arthroscopy 2022; 38:466-473.e1. [PMID: 34126218 DOI: 10.1016/j.arthro.2021.05.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective was to (1) evaluate any recent changes in the United States in the incidences of medial patellofemoral ligament (MPFL) reconstruction and isolated lateral release for patellar instability in children and adolescents, (2) identify concomitant procedures with MPFL, and (3) report national complication rates after MPFL reconstruction with and without concomitant procedures in children and adolescents. METHODS A national database was queried for patients aged 5 to 18 years who underwent operative treatment for patellar instability from 2010 to 2018. Inclusion criteria were either an MPFL reconstruction or lateral release for a diagnosis of patellar instability. Concomitant procedures with MPFL reconstruction assessed were tibial tubercle osteotomy, associated arthroscopic procedures, and lateral release. Changes in incidence in MPFL reconstruction, lateral release and concomitant procedures were assessed. The following postoperative complications were assessed: knee stiffness, infection, patella fracture, and growth arrest or angular deformity. RESULTS 2,161 patients who underwent MPFL reconstruction and 1,159 patients who underwent isolated lateral release for patellar instability were identified. The incidence of MPFL reconstruction in adolescents from 2010 to 2018 did not change significantly (2010: 7.11, 2018: 5.91, P = .137), while isolated lateral release decreased (2010: 6.06, 2018: 1.83, P < .0001). Concomitant procedures with MPFL reconstruction were common, with arthroscopy being the most frequent (58-67%). The most common complication within 90 days of surgery was patella fracture (0.4% to 2.0%). Infection (0.4% to 1.0%) and growth arrest (0.09% to 0.61%) were the least common. MPFL and arthroscopy had a decreased risk of growth arrest following surgery compared to MPFL alone (P = .038). CONCLUSIONS The incidence of MPFL reconstruction remained high from 2010 to 2018, while isolated lateral release decreased during the same time period. Complications after MPFL reconstruction, isolated lateral release, and concomitant procedures were infrequent, with postoperative patella fracture the most common. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Jeremy K Rush
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Samuel R Montgomery
- School of Medicine, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Migliorini F, Marsilio E, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. Chondral injuries in patients with recurrent patellar dislocation: a systematic review. J Orthop Surg Res 2022; 17:63. [PMID: 35101078 PMCID: PMC8802427 DOI: 10.1186/s13018-022-02911-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/03/2022] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background
Patellar dislocations in patients presenting with recurrent patellofemoral instability can damage the surrounding structures, limiting patient’s participation to recreational activities and quality of life. This study evaluated frequency, location, and extent of associated injuries in patients with recurrent patellar dislocation.
Methods
This systematic review was conducted according to the PRISMA checklist. PubMed, Google scholar, Embase, and Web of Science databases were accessed in July 2021. All the published clinical studies reporting frequency, location, and extent of soft tissue lesions in patients with recurrent patellar dislocations were accessed.
Results
Data from 9 articles (232 patients) were retrieved. The mean age of the included patients was 21.2 ± 5.6 years. 84.8% of patients suffering from recurrent patellar dislocations demonstrated patellar chondral defects: medial facet (34.9%), while patellar crest (34.8%) and lateral facet (17%). 27.8% of patients demonstrated trochlear chondral injuries.
Conclusion
Chondral defects of the medial facet and the crest of the patella are the most common in patients with recurrent patellofemoral instability.
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Migliorini F, Marsilio E, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. Chondral and Soft Tissue Injuries Associated to Acute Patellar Dislocation: A Systematic Review. Life (Basel) 2021; 11:life11121360. [PMID: 34947891 PMCID: PMC8706453 DOI: 10.3390/life11121360] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Chondral and soft tissue injuries can be associated with first time patellar dislocation, but it is unclear how common they are, and which tissues are affected. A systematic review of the literature was performed to investigate the frequency, location, and extent of chondral and medial patellofemoral ligament (MPFL) injuries in patients following first time patellar dislocation. METHODS This systematic review was conducted according to the PRISMA guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in November 2021. All the published clinical studies reporting the frequency, location, and extent of soft tissue lesions following first time patellar dislocation were accessed. Studies reporting data on habitual, congenital, or recurrent patellofemoral instability were excluded. RESULTS Data from 42 articles (2254 patients, mean age 21.6 ± 7.3 years) were retrieved. Ninety-eight percent of patients who experienced first time patellar dislocation demonstrated MPFL rupture at MRI. Forty-eight percent of MPFL ruptures were located at the patellar side, 34% at the femoral insertion site, and 18% in the midportion. Eighty-five percent of patients showed signs of patellar chondral damage at MRI, and trochlear chondral injuries were evidenced in 47% of patients. Intra-articular loose bodies were observed in 11.5% of patients. At arthroscopy, the medial facet and the crest of the patella more commonly exhibited chondral lesions than the lateral facet and femoral trochlea. CONCLUSIONS Most patients suffer chondral damage and MPFL tears following after a first time patellar dislocation.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Emanuela Marsilio
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Cuozzo
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Francesco Oliva
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
| | - Jörg Eschweiler
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Frank Hildebrand
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52064 Aachen, Germany; (J.E.); (F.H.)
| | - Nicola Maffulli
- Department of Orthopaedics, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy; (E.M.); (F.C.); (F.O.); (N.M.)
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London E1 4DG, UK
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST5 5BG, UK
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Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques. Life (Basel) 2021; 11:life11060543. [PMID: 34200546 PMCID: PMC8226590 DOI: 10.3390/life11060543] [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] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
Large (>3 cm2), focal osteochondral lesions (OCL) may result in poor functional outcomes and early secondary osteoarthritis of the knee. The surgical management of these OCL remains challenging. The treatment strategy must be tailored to various aspects, including lesion-specific (e.g., size, location, chronicity), joint-specific (e.g., instability, limb alignment, meniscal status), and patient-specific factors (e.g., age, activity level, comorbidities). Simple chondroplasty and bone marrow stimulation (BMS) techniques should be reserved for smaller lesions, as they only realize midterm clinical benefits, related to inferior wear characteristics of the induced fibrocartilage (type I collagen). Therefore, much attention has been focused on surgical restoration with hyaline cartilage (type II collagen), based on chondrocyte transplantation and matrix-assisted autologous chondrocyte implantation (MACI). Limited graft availability, staged procedures (MACI), and high treatment costs are limitations of these techniques. However, acute traumatic OCL of the femoral condyles and patellofemoral joint may also be suitable for preservation by surgical fixation. Early detection of the fragment facilitates primary repair with internal fixation. The surgical repair of the articular surface may offer promising clinical and cost-effective benefits as a first-line therapy but remains under-investigated and potentially under-utilized. As a unique characteristic, the fixation technique allows the anatomic restoration of the hyaline articular surface with native cartilage and the repair of the subchondral bone. In this manuscript, we present a case series of large OCL around the knee that were preserved by surgical fixation. Furthermore, various implants and techniques reported for this procedure are reviewed.
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Aicale R, Maffulli N. Combined medial patellofemoral and medial patellotibial reconstruction for patellar instability: a PRISMA systematic review. J Orthop Surg Res 2020; 15:529. [PMID: 33183310 PMCID: PMC7663880 DOI: 10.1186/s13018-020-02072-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart stability to the patellofemoral joint. The anatomy and biomechanical characteristics of the MPFL have been well described but little is known about the MPTL and MPML. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, patellar and quadriceps tendons, allografts and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. METHODS A systematic review of the literature was conducted using PRISMA guidelines. Inclusion criteria were articles that reported clinical outcomes of combined reconstruction of MPTL and MPFL. The methodological quality of the articles was determined using the modified Coleman Methodology Score (CMS). RESULTS Nine articles were included, reporting the clinical outcomes of 197 operated knees. The surgical procedures described include hamstrings grafting and transfer of the medial patellar and quadriceps tendons with or without bony procedures to reconstruct the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved. The median CMS is 70.6 ± 14.4 (range 38 to 84). CONCLUSION Different techniques are reported, and outcomes are good with low rates of recurrence. The quality of the articles is variable, ranging from low to high. Appropriately powered randomized controlled trials are needed to better understand what the adequate indications for surgery in patients with patellar instability and clinical outcomes are. Combined reconstruction of MPFL and MPTL leads to favourable clinical outcomes, supporting its role as a valid surgical procedure for patellar stabilization.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG England
- Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB England
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Kumar A, Haider Y, Jameel J, Qureshi OA. Combined medial patellofemoral and patellotibial reconstruction with soft tissue fixation in recurrent patellar dislocation: Some concerns. Injury 2020; 51:2339. [PMID: 32605786 DOI: 10.1016/j.injury.2020.06.047] [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: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, HIMSR, New Delhi 110062, India
| | - Yawar Haider
- Department of Orthopaedics, HIMSR, New Delhi 110062, India.
| | - Javed Jameel
- Department of Orthopaedics, HIMSR, New Delhi 110062, India
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