1
|
Phillips AR, Singh H, Haneberg EC, Danilkowicz RM, Yanke AB. Isolated Medial Patellofemoral Ligament Reconstruction Results in Lower Failure and Complication Rates Than Isolated Trochleoplasty and Tibial Tubercle Osteotomy: A Systematic Review. Arthroscopy 2024:S0749-8063(24)00396-7. [PMID: 38844012 DOI: 10.1016/j.arthro.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE To evaluate outcomes and complications of isolated medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), and trochleoplasty for management of patellar instability. METHODS A query of Scopus, PubMed, Google Scholar, Cochrane CENTRAL Register of Controlled Trials, and the Cochrane Database of Systematic Reviews was performed in accordance with 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies reported clinical outcome data after isolated MPFLR, TTO, or trochleoplasty for patellar instability with a minimum 12-month follow-up. Meta-analysis and data aggregation was not performed. RESULTS Thirty-six studies (5 trochleoplasty, 14 TTO, and 18 MPFLR) consisting of 1,389 patients (114 trochleoplasty, 374 TTO, and 1,001 MPFLR) were included. Risk of bias was assessed with the Methodological Index for Non-Randomized Studies score, which ranged from 11 to 12 in trochleoplasty, 10 to 18 in TTO, and 8 to 18 in MPFLR studies. Patient-reported outcome measures, including Lysholm score (trochleoplasty: 51.1-71 to 71-95; TTO: 57-63.3 to 84-98; MPFLR: 37.4-59.1 to 74-92.5), Kujala score (trochleoplasty: 56-71 to 78-92; TTO: 48.6-68 to 78-92; MPFLR: 53.3-60 to 81.5-92), visual analog scale for pain (trochleoplasty: 52-25; TTO: 54-76 to 14-27; MPFLR: 29 to 17, out of 100), and Tegner score (TTO: 3-4 to 3-4; MPFLR: 2.5-6 to 4.9-5), improved after all surgeries. Failure rates ranged from 0% to 33.3% after MPFLR, 0% to 30.8% after TTO, and 5.3% to 40% after trochleoplasty. Complication rates ranged from 0% to 14.7% after MPFLR, 1.6% to 58.3% after TTO, and 8% to 26.3% after trochleoplasty. CONCLUSIONS Isolated MPFLR, TTO, or trochleoplasty may be effective treatment options for patellar stabilization. Although failure rates were highest after isolated trochleoplasty and complication rates were highest after TTO, these procedures are not interchangeable as each addresses a specific pathology. LEVEL OF EVIDENCE Level IV, systematic review of Level II to IV studies.
Collapse
Affiliation(s)
- Andrew R Phillips
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harmanjeet Singh
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Erik C Haneberg
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Richard M Danilkowicz
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A..
| |
Collapse
|
2
|
Uppstrom TJ, Fletcher CF, Green DW, Gomoll AH, Strickland SM. Decreased Effective Patellar Tendon Length following Distalization Tibial Tubercle Osteotomy without Patellar Tendon Tenodesis. Orthop J Sports Med 2024; 12:23259671241227201. [PMID: 38371997 PMCID: PMC10870814 DOI: 10.1177/23259671241227201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 02/20/2024] Open
Abstract
Background Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. Purpose To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Study Design Case series; Level of evidence, 4. Methods Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. Results The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Conclusion Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.
Collapse
Affiliation(s)
- Tyler J. Uppstrom
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Connor F. Fletcher
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W. Green
- Department of Pediatric Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Andreas H. Gomoll
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | | |
Collapse
|
3
|
Murakami S, Shimada M, Hara Y. Examination of Proximodistal Patellar Position in Dogs with the Stifle at Full Extension. Vet Comp Orthop Traumatol 2023; 36:199-206. [PMID: 36940719 DOI: 10.1055/s-0043-1764317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
OBJECTIVE The aim of this study was to determine the factors related to functional patella alta, with which the proximodistal patellar position exceeds the reference range of healthy small dogs proximally when the stifle is at full extension. STUDY DESIGN Mediolateral-view radiographs of dogs weighing less than 15 kg were obtained and classified into the medial patellar luxation (MPL) and control groups. The reference range of the proximodistal patellar position was determined from the control group. In both groups, a patellar position exceeding this reference range proximally was considered functional patella alta. Multiple logistic regression analysis was performed to examine the factors related to functional patella alta. A receiver operating characteristic (ROC) curve was made for each factor. RESULTS Overall, radiographs of 127 stifles of 75 dogs were obtained. Eleven stifles in the MPL group and one stifle in the control group were determined to be functional patella alta. The factors associated with functional patella alta included a greater full extension angle of the stifle joint, longer patellar ligament, and shorter femoral trochlear length. The full extension angle of the stifle joint had the biggest area under the ROC curve. CONCLUSION Mediolateral radiographs of the stifle joint in full extension are clinically important in dogs with MPL because some dogs might have a proximally positioned patella that is recognizable only when the stifles are extended.
Collapse
Affiliation(s)
- Sawako Murakami
- Department of Veterinary Surgery, Division of Veterinary Science, Section of Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan
| | - Masakazu Shimada
- Department of Veterinary Surgery, Division of Veterinary Science, Section of Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan
| | - Yasushi Hara
- Department of Veterinary Surgery, Division of Veterinary Science, Section of Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Dickschas J. [Osteotomy in patellofemoral malalignment]. SPORTVERLETZUNG-SPORTSCHADEN 2021; 35:210-217. [PMID: 34883520 DOI: 10.1055/a-1486-1804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anterior knee pain and patellofemoral instability are the two major symptoms of patellofemoral dysbalance. Various pathologies can cause these symptoms. In recent years, axis deviations have been increasingly discussed as a cause of patellofemoral dysbalance. In the frontal axis, valgus deformities are a major risk factor, but torsional deformities may be a cause as well. Increased femoral internal rotation or increased tibial external rotation are the key pathologies. Osteotomy is the treatment of choice. Valgus deformities require varisation osteotomy, which is either performed on the femur or tibia depending on the location of the deformity. Torsional deformities are treated by external femoral or internal tibial torsional osteotomy. Femoral osteotomies are located above the femoral condyles, tibial osteotomies above the tibial tuberosity. Tibial internal torsional correction must not exceed 15° because this would jeopardise structures such as the peroneal nerve. Rehabilitation includes partial weight-bearing for four to six weeks. Hardware removal can be performed half a year after osteotomy. The relevance of axis deviations and treatment by osteotomy in patellofemoral dysbalance has been highlighted in recent reviews. Several publications report promising results after osteotomy, including significant pain relief and achievement of patellofemoral stability.
Collapse
Affiliation(s)
- Joerg Dickschas
- Klinik für Orthopädie und Unfallchirurgie, SozialStiftung Bamberg, Germany
| |
Collapse
|
6
|
Clinical Improvement Is Achieved Following Tibial Tubercle Distomedialization for Patellar Maltracking and Patella Alta Without Instability. Arthrosc Sports Med Rehabil 2021; 3:e845-e853. [PMID: 34195653 PMCID: PMC8220615 DOI: 10.1016/j.asmr.2021.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/27/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose To determine short-term patient-reported outcomes following distomedial tibial tubercle transfer (TTT) in patients with patellar maltracking and patella alta without instability. Methods A single-surgeon case series study was performed on patients receiving distomedial TTT for the indication of patellar maltracking and patella alta without instability, after nonresponse to conservative treatment. Patient-reported outcomes were assessed preoperatively and at 3-, 6-, 12-, and 24-month follow-up using Kujala, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analog scale (VAS) pain scores. Generalized estimating equations analyses were performed to study improvement over time. Minimal clinically important differences obtained from literature were used to determine clinical relevance. Results A total of 40 patients were included. Eight patients were lost to follow-up; thus, outcomes of 32 patients were analyzed. Mean follow-up was 22 months, median age was 21 years, and 75% were female. Mean Kujala score increased pre- to postoperatively from 55 ± 12 to 79 ± 16 (P < .001), KOOS from 48 ± 14 to 79 ± 15 (P < .001), and VAS from 64 ± 17 to 25 ± 21 (P < .001), respectively. Eighty-four percent had clinical improvement of Kujala score, 91% of KOOS, and 78% of VAS score. A plateau phase in pain reduction was reached at 3 months, and in functional improvement at 6 months follow-up, after which no further significant improvement was observed. Complication rate was 3% and removal of hardware rate was 72%. Conclusions: In this case series study, distomedial TTT led to clinically relevant functional improvement and pain reduction in patients with patellar maltracking and patella alta without instability. However, the removal of hardware rate was high (72%). Level of Evidence Level IV, therapeutic case series.
Collapse
|
7
|
Tan SHS, Ngiam EHK, Lim JY, Lim AKS, Hui JH. Surgical Management of Patella Alta in Patellofemoral Instability: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:2325967121999642. [PMID: 33997063 PMCID: PMC8072862 DOI: 10.1177/2325967121999642] [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: 11/01/2020] [Accepted: 12/11/2020] [Indexed: 11/15/2022] Open
Abstract
Background Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition. Purpose To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques. Study Design Systematic review; Level of evidence, 4. Methods This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators. Results A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48). Conclusion Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.
Collapse
Affiliation(s)
- Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Jia Ying Lim
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - James Hoipo Hui
- Department of Orthopaedic Surgery, National University Health System, Singapore
| |
Collapse
|
8
|
Tibial tubercle transfer leads to clinically relevant improvement in patients with patellar maltracking without instability: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:1137-1149. [PMID: 32594329 DOI: 10.1007/s00167-020-06114-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/11/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE To assess the different surgical techniques and their outcomes following tibial tubercle transfer (TTT) in patients with patellar maltracking. METHODS A systematic search of the literature was performed in PubMed, EMBASE and Cochrane Library. Studies reporting patient-reported outcome measures (PROMs) or clinical outcome following: TTT in patients with patellar maltracking were included. Collected PROMs were Lysholm, Kujala, IKDC score, and VAS pain. Clinical outcome included reported clinical success, patient satisfaction, complications and removal of hardware (ROH). Overall pre-, post-operative and change scores were estimated using random-effects meta-analysis models. Results were reported as overall mean and per transfer direction. RESULTS A total of 26 studies and 761 patients (818 knees, mean age 35 years, mean follow-up 5.0 years) were included. In 73% of the studies, surgery was performed after failed conservative treatment. Transfer direction was anteromedial in 76% of all procedures. Overall Lysholm score improved from 61 to 91, Kujala from 52 to 85, IKDC from 53 to 81, and VAS from 6.2 to 2.5, respectively. Clinical success was reported in 79% of patients, and 80% of patients reported to have satisfactory results. Rates of complications and ROH were 13% and 29%, respectively. CONCLUSIONS TTT for management of patellar maltracking can lead to good results with clinically meaningful improvement, an overall clinical success of 79% and overall patient satisfaction of 80% when appreciating the underlying anatomic condition and using appropriate technique. The level of evidence was low, and large-scale prospective, comparative cohort studies with uniform outcome scales are needed to confirm these findings. LEVEL OF EVIDENCE IV.
Collapse
|
9
|
Leite CBG, Santos TP, Giglio PN, Pécora JR, Camanho GL, Gobbi RG. Tibial Tubercle Osteotomy With Distalization Is a Safe and Effective Procedure for Patients With Patella Alta and Patellar Instability. Orthop J Sports Med 2021; 9:2325967120975101. [PMID: 33553451 PMCID: PMC7829522 DOI: 10.1177/2325967120975101] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Tibial tubercle osteotomy with concomitant distalization for the treatment of
patellar instability remains controversial, as it may cause anterior knee
pain and chondral degeneration. Purpose: To evaluate radiographic, clinical, and functional outcomes in patients who
had patellar instability with patella alta and underwent tibial tubercle
osteotomy with distalization (TTO-d) as well as medial patellofemoral
ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 25 patients (31 cases) (mean age at surgery, 28.7
years; range, 14-33 years) with patellar instability and patella alta who
underwent TTO-d with minimum 1-year follow-up. The Caton-Deschamps index
(CDI), tibial tubercle–trochlear groove (TT-TG) distance, and amount of
distalization were assessed. Clinical and functional variables included
J-sign, anterior knee pain, apprehension test, Tegner activity level, and
Kujala score. Results: The mean follow-up period was 2.62 years. The mean TT-TG was 16.15 mm (range,
7-24 mm); the mean CDI changed from 1.37 (1.25-1.7) preoperatively to 1.02
(0.9-1.12) postoperatively (P = .001); and the mean amount
of tibial tubercle distalization was 8.80 mm (range, 4-16 mm). Lateral
release (22 cases; 71.0%), medialization of tibial tubercle (17 cases;
54.8%), and autologous chondrocyte implantation (4 cases; 12.9%) were other
associated procedures. The J-sign improved in 30 cases (96.8%;
P = .001), and there was a complete resolution of
anterior knee pain in 22 cases (71.0%; P = .001). An
exploratory analysis showed that patellar cartilage defect severity was
correlated with persistent pain (P = .005). The
apprehension test became negative in all cases (P = .001).
The median Kujala score increased from 52 to 77 (P = .001),
and the median Tegner activity level improved from 3 to 4
(P = .001). No cases of osteotomy nonunion were
reported. One case (3.2%) of patellar instability recurrence and 3 cases
(6.5%) with painful hardware were observed. Conclusion: TTO-d resulted in good radiographic, clinical, and functional outcomes
providing proper patellar stability to patients with patella alta. TTO-d
appears to be a safe and efficient procedure with low complication rates,
providing an additional tool for the personalized treatment of patellar
instability.
Collapse
Affiliation(s)
- Chilan B G Leite
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Társis P Santos
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Pedro N Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José R Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto L Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo G Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
10
|
Tibia Tubercle Distalization Osteotomy. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Vellios EE, Trivellas M, Arshi A, Beck JJ. Recurrent Patellofemoral Instability in the Pediatric Patient: Management and Pitfalls. Curr Rev Musculoskelet Med 2020; 13:58-68. [PMID: 31983043 DOI: 10.1007/s12178-020-09607-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of the review is to discuss the relevant pathoanatomy, management, complications, and technical considerations for recurrent patellofemoral instability (PFI) in the pediatric population. Special consideration is given to recent literature and management of the patient with repeat instability following surgery. RECENT FINDINGS Patellar stabilization surgery is in principle dependent upon restoration of normal patellofemoral anatomy and dynamic alignment. Historically, treatment options have been numerous and include extensor mechanism realignment, trochleoplasty, and more recently repair and/or reconstruction of the medial patellofemoral ligament (MPFL) as a dynamic check rein during initial knee flexion. In skeletally immature patients, preference is given to physeal-sparing soft tissue procedures. While medial patellofemoral ligament reconstruction has become a popular option, postoperative failure is a persistent issue with rates ranging from 5 to 30% for PFI surgery in general without any single procedure (e.g., distal realignment, MPFL reconstruction) demonstrating clear superiority. Failure of surgical patellar stabilization is broadly believed to occur for three main reasons: (1) technical failure of the primary stabilization method, (2) unaddressed static and dynamic pathoanatomy during the primary stabilization, and (3) intrinsic risk factors (e.g., collagen disorders, ligamentous laxity). PFI is a common orthopedic condition affecting the pediatric and adolescent population. Treatment of repeat instability following surgery in the PFI patient requires understanding and addressing underlying pathoanatomic risk factors as well as risks and reasons for failure.
Collapse
Affiliation(s)
- Evan E Vellios
- Sports Medicine and Shoulder Service Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Myra Trivellas
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
| |
Collapse
|