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Hysing‐Dahl T, Inderhaug E. Rehabilitation after surgery for patellar instability. J Exp Orthop 2024; 11:e12062. [PMID: 38887658 PMCID: PMC11180699 DOI: 10.1002/jeo2.12062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/23/2024] [Accepted: 04/22/2024] [Indexed: 06/20/2024] Open
Affiliation(s)
- Trine Hysing‐Dahl
- Department of SurgeryHaraldsplass Deaconess HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Eivind Inderhaug
- Department of SurgeryHaraldsplass Deaconess HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of Orthopaedic SurgeryHaukeland University HospitalBergenNorway
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Barton KI, Boldt KR, Sogbein OA, Steiner NJ, Moatshe G, Arendt E, Getgood A. Femoral internal torsion greater than twenty-five degrees and/or external tibial torsion greater than thirty degrees as measured by computed tomography are threshold values for axial alignment correction in patellofemoral instability. J ISAKOS 2024; 9:386-393. [PMID: 38365167 DOI: 10.1016/j.jisako.2024.02.002] [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: 10/05/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES Patellofemoral instability (PFI) has multiple predisposing anatomic factors, including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea dysplasia, excessive lateral patellar tilt, and excessive lateral Q vector. Yet, few studies have analyzed surgical thresholds for performing axial alignment corrective osteotomies in the treatment of PFI and patella maltracking. The objective of this systematic literature review was to determine if there is a threshold for axial plane alignment that triggers surgical correction for the treatment of patellar instability in the published literature. METHODS Using a predetermined search strategy, a systematic literature search of 10 major databases and gray literature resources was completed. Only studies reporting on patellar instability and outcomes were included. Radiologic indications, additional procedures, outcomes, and complications were reported. Titles and abstracts were screened, and full-text manuscripts were then selected and extracted. Variables related to radiographic and clinical parameters, patient demographics, surgery performed, surgical correction, complications, and reoperations were recorded preoperatively and postoperatively. RESULTS A total of 1132 abstracts and titles were screened by two reviewers, yielding 15 eligible studies. The reported threshold identified in our study for axial plane alignment that triggers surgical correction in most of the published literature when discussing PFI was either tibial torsion greater than 30° and/or femoral anteversion greater than 25°. Following rotational osteotomy of one or both long bones, one study (7%) reported improvements in tubercle-sulcus angle, two studies (13%) reported improvements in femoral-tibial angle, and four studies (27%) reported decreases in tibial torsion. For patient-reported outcomes, seven studies (47%) reported improvement in the Kujala score, five studies (33%) reported postoperative improvement in Lysholm, and four studies (27%) reported improvement in the International Knee Documentation Committee (IKDC) score. Nine studies (60%) reported preoperative femoral anteversion; however, only two studies compared pre- and post-operative values (one study reported a decrease in anteversion and another study reported an increase in anteversion). CONCLUSION When treating PFI, the reported threshold for axial plane alignment that triggers surgical correction in most of the published literature was tibial torsion greater than 30° and/or femoral anteversion greater than 25° as measured by CT. However, there is no consensus on the axial alignment measurement technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kristen I Barton
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, N6G 2V4, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, N6A 3K7, Canada; Faculty of Health Sciences, Western University, London, ON, N6A 3K7, Canada.
| | - Kevin R Boldt
- School of Kinesiology, Trent University, Peterborough, ON, K9L 0G2, Canada
| | - Olawale A Sogbein
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, N6G 2V4, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, N6A 3K7, Canada
| | - Nicholas J Steiner
- Faculty of Health Sciences, Western University, London, ON, N6A 3K7, Canada
| | | | | | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, N6G 2V4, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, N6A 3K7, Canada; Faculty of Health Sciences, Western University, London, ON, N6A 3K7, Canada
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Figueroa F, Guiloff R, Bolton S, Figueroa D, Tapasvi S, Stocker E. Specific considerations in female patients with patellar instability: current concepts. J ISAKOS 2024; 9:457-463. [PMID: 38580053 DOI: 10.1016/j.jisako.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/07/2024]
Abstract
Prior literature suggests that patellofemoral instability (PFI) is significantly more prevalent in women than in men. This higher prevalence is commonly attributed to anatomical differences between sexes, particularly with patellofemoral alignment. These differences encompass a higher rate of trochlear dysplasia (TD), patella alta, an increased Q angle, and soft tissue imbalances. In recent years, worse outcomes have been reported in female patients after patellofemoral stabilization surgery using medial patellofemoral ligament reconstruction (MPFLr) alone or in combination with a tibial tubercle osteotomy (TTO), for this reason an "à la carte" plan (addressing the individuals anatomical risk factors) could be more appropriate for female patients.
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana-Universidad del Desarrollo, 7650568, Chile; Hospital Sotero del Rio, 8207257, Chile.
| | - Rodrigo Guiloff
- Clinica Alemana-Universidad del Desarrollo, 7650568, Chile; Hospital Sotero del Rio, 8207257, Chile.
| | - Sarah Bolton
- Fortius Clinic, W1H 6EQ, UK; Chelsea & Westminster Hospital, SW10 9NH, UK.
| | - David Figueroa
- Clinica Alemana-Universidad del Desarrollo, 7650568, Chile.
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Hinckel B, Smith J, Tanaka MJ, Matsushita T, Martinez-Cano JP. Patellofemoral instability part 1 (When to operate and soft tissue procedures): State of the art. J ISAKOS 2024:S2059-7754(24)00100-7. [PMID: 38795864 DOI: 10.1016/j.jisako.2024.05.013] [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: 02/23/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation, and patellar height. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.
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Affiliation(s)
- Betina Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Justin Smith
- Atrium Health Musculoskeletal Institute & Sports Medicine, Rock Hill, SC, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Hysing-Dahl T, Magnussen LH, Faleide AGH, Inderhaug E. Feasibility of return to sports assessment 6 months after patellar instability surgery. BMC Musculoskelet Disord 2023; 24:662. [PMID: 37596551 PMCID: PMC10439663 DOI: 10.1186/s12891-023-06767-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/29/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND The evidence regarding the usefulness of assessment tools to support decisions of return-to-sport after surgery for patellar instability is scarce. The purpose of this study was therefore to explore the feasibility of functional tests assessing readiness for return-to-sport six months after patellar stabilizing surgery. However, there is little evidence on what a functional assessment should include to support these decisions following surgery for patellar instability. Therefore the purpose of this study was to explore the feasibility of functional tests assessing readiness for return-to-sport six months after patellar stabilizing surgery. METHODS In this cross-sectional study a prospective cohort of 78 patients were subjected to a range of return-to-sport readiness tests at six months after surgery for patellar instability with an "a la carte" approach. Lower Quarter Y-Balance Test (YBT-LQ), single-legged hop tests and isokinetic strength tests were performed. In addition, self-reported function was measured with the Banff Patellofemoral Instability Instrument 2.0 (BPII) and Norwich Patellar Instability score (NPI). Return-to-sport clearance criteria were defined as: ≤4 cm YBT-LQ anterior reach difference between legs, leg-symmetry-index (LSI) ≥ 95% in the YBT-LQ composite score, mean sum score LSI ≥ 85% of all single-leg hop tests and LSI ≥ 90% in isokinetic quadriceps strength. RESULTS Sixty-four patients (82%) were able to complete all functional tests, while only eleven (14%) patients were deemed ready for return-to-sport, passing all return-to-sport clearance criteria. Patients with bilateral problems demonstrated worse performance in the contralateral leg, which resulted in higher LSI scores compared to individuals with unilateral instability. A supplementary finding was that the extent of surgery (MPFL-R only versus combined surgery) did not predict and mainly did not affect self-reported function or functional performance at the follow-up. CONCLUSION The functional assessment used in the current study seems feasible to conduct at six months after patellar stabilizing surgery. However, current suggested clearance standards and the use of leg-symmetry-index seems inappropriate for patients with patellar instability. Therefore, further exploration of appropriate tests and return-to-sport clearance criteria is justified. TRIAL REGISTRATION clinicaltrial.gov, NCT05119088. Registered 12.11.2021 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05119088 .
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Affiliation(s)
- Trine Hysing-Dahl
- Haraldsplass Deaconess Hospital, V/Avdeling for Rehabiliteringstjenester Postboks 6165, Bergen, 5892, Norway.
- University of Bergen, Bergen, Norway.
| | - L H Magnussen
- Western Norway University of Applied Science, Haugesund, Norway
| | - A G H Faleide
- Haraldsplass Deaconess Hospital, V/Avdeling for Rehabiliteringstjenester Postboks 6165, Bergen, 5892, Norway
| | - E Inderhaug
- Haukeland University Hospital, Bergen, Norway
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Hysing-Dahl T, Inderhaug E, Faleide AGH, Magnussen LH. Patients' experiences of living with patellar instability before and after surgery: a qualitative interview study. BMJ Open 2023; 13:e072141. [PMID: 37295823 PMCID: PMC10277117 DOI: 10.1136/bmjopen-2023-072141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVES To explore the experience of living with patellar instability before and after surgery. DESIGN Qualitative individual semistructured interviews of patients with patellar instability using a four-step thematic cross-case analysis strategy (systematic text condensation). SETTING Two orthopaedic units within two large Hospitals in Norway. PARTICIPANTS A convenience sample of 15 participants, aged between 16 and 32 years, who had undergone surgery for patellar instability within the last 6-12 months. RESULTS Participants offered rich and detailed descriptions of the impact and lived experience of patellar instability, including fear of new dislocations, increased awareness of the knee and adaptations to avoidance behaviour in everyday life both before and after surgery. The four major themes that emerged from the data were: (1) fear of patella dislocations governs everyday life activities, (2) adaptation to avoidance behaviour, (3) feeling different, misunderstood and stigmatised affects self-esteem and (4) feeling stronger, but still not fully confident in the knee after surgery. CONCLUSIONS These findings offer insight into the experience of living with patellar instability. Patients reported that the instability had major impacts on their everyday life, affecting ability to participate in social life and physical activities both before and after surgery. This may imply that an increased attention towards cognitive interventions may be useful in the management of patellar instability. TRIAL REGISTRATION NUMBER NCT05119088.
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Affiliation(s)
- Trine Hysing-Dahl
- Department of Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway
- University of Bergen, Bergen, Norway
| | - Eivind Inderhaug
- University of Bergen, Bergen, Norway
- Haukeland Universitetssjukehus, Bergen, Norway
| | - Anne Gro Heyn Faleide
- Department of Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway
- University of Bergen, Bergen, Norway
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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: 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: 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.
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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
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Swinging injuries in competitive baseball players. Skeletal Radiol 2022; 52:1277-1292. [PMID: 36542131 DOI: 10.1007/s00256-022-04261-9] [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: 10/05/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Injuries are common in competitive baseball players and can occur in all facets of the game. The majority of the existing literature on injuries in baseball players has focused on injuries secondary to the overhead throw with very little attention given to injuries sustained while batting. The baseball swing is a complex, often violent, motion that predisposes batters to a variety of injuries affecting the spine, trunk, pelvis, and extremities. Knowledge of injury patterns that commonly occur during the baseball swing and radiologic findings important to the treating physician can help radiologists provide accurate imaging interpretations that appropriately guide patient management.
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High incidence of complication following tibial tubercle surgery. J ISAKOS 2022; 8:81-85. [PMID: 36435429 DOI: 10.1016/j.jisako.2022.11.005] [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: 04/22/2022] [Revised: 10/06/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Tibial tubercle osteotomy (TTO) is a common procedure that is frequently used in the treatment of recurrent patellar instability and/or patellar chondrosis. Current estimates of TTO complications in the literature vary widely, with complication rates reaching 59 percent. This variability is due, in part, to inconsistent definitions of complication between studies. The purpose of this study was to identify our complication rate following TTO procedures, with sub-analysis of whether the complication rate was affected by: 1. An intra-articular component defined as an additional procedure that altered post-operative rehabilitation and 2. A distalization of the tubercle translation. METHODS All patients between May 2009 and May 2015 who underwent a TTO were retrospectively identified. Complications were defined as major (fracture of the tibia, deep infection, non-union, delayed union, arthrofibrosis, deep vein thrombosis (DVT) and loss of screw fixation) versus minor (superficial wound infection, disturbance of cutaneous sensation and delay in wound healing). Subgroup analysis of distalization versus no distalization and intra-versus extra-articular concomitant procedures were also analysed. RESULTS One hundred and sixty-three TTOs in 150 patients were included in the final cohort with a mean follow-up of 21.3 months. The overall complication rate was 35 major complications (21.5%) and 13 minor complications (8.0%), with a total complication rate of 29.5 percent. TTO distalization did not increase the rate of complications. DVT was only seen in the intra-articular procedure cohort (n = 3/1.8%). Arthrofibrosis was the most common complication, occurring in 17 knees. CONCLUSION The overall complication rate of TTOs was 29.5%, with arthrofibrosis (10.4%) as the largest complication. DVT increased with concomitant intra-articular procedure. Distalization of the tubercle compared to no distalization had no significant effect on complications. LEVEL OF EVIDENCE Retrospective Cohort study, level III.
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D'Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior Knee Pain: State of the Art. SPORTS MEDICINE - OPEN 2022; 8:98. [PMID: 35907139 PMCID: PMC9339054 DOI: 10.1186/s40798-022-00488-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022]
Abstract
Anterior knee pain (AKP) is one of the most common conditions to bring active young patients to a sports injury clinic. It is a heterogeneous condition related to multiple causative factors. Compared to the general population, there appears to be a higher risk of development of patellofemoral osteoarthritis in patients with AKP. AKP can be detrimental to the patient’s quality of life and, in the larger context, significantly burdens the economy with high healthcare costs. This study aims to present a comprehensive evaluation of AKP to improve clinical daily practice. The causes of AKP can be traced not only to structures within and around the knee, but also to factors outside the knee, such as limb malalignment, weakness of specific hip muscle groups, and core and ligamentous laxity. Hence, AKP warrants a pointed evaluation of history and thorough clinical examination, complemented with relevant radiological investigations to identify its origin in the knee and its cause. Conservative management of the condition achieves good results in a majority of patients with AKP. Surgical management becomes necessary only when it is deemed to provide benefit—when the patient has well-characterized structural abnormalities of the knee or limb that correlate with the AKP clinically or in situations where the patient does not obtain significant or sustained relief from symptoms. AKP has a multifactorial etiology. The treatment strategy must be individualized to the patient based on the patient profile and specific cause identified. Hence, treatment of AKP warrants a pointed evaluation of history and thorough clinical examination complemented with relevant radiological investigations to identify the condition’s origin and its cause. A holistic approach focused on the patient as a whole will ensure a good clinical outcome, as much as a focus on the joint as the therapeutic target.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università Degli Studi Di Milano, Milan, Italy.
| | - Amit Meena
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Akshya Raj
- Central Institute of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Nicola Ursino
- IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161, Milan, Italy
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Waaler PAS, Jellestad T, Hysing-Dahl T, Elvehøy E, Inderhaug E. Insall proximal realignment with/without tibial tubercle osteotomy for recurrent patellar instability yields acceptable medium- to long-term results but risk of osteoarthritis progression is considerable. J Exp Orthop 2022; 9:64. [PMID: 35793010 PMCID: PMC9259772 DOI: 10.1186/s40634-022-00502-x] [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: 05/12/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate clinical and radiological results in patients operated for recurrent patellar instability with a surgical approach consisting of Insall proximal realignment with/without tibial tubercle osteotomy (TTO). METHODS Patients that underwent surgery for recurrent patellar instability at one centre with a uniform technique between 2004 and 2020 were included. Eligible patients were assessed by clinical examination and the disease-specific Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0). Pre- and postoperative radiographs were analysed for patellofemoral osteoarthritis (OA) according to Iwano. Preoperative Magnetic Resonance Imaging (MRI) and radiographs were analysed for anatomical risk factors for patellar instability. Student t-test, chi-square test and ANOVA-analyses were used to investigate whether anatomical risk factors and/or patient characteristics could predict an inferior outcome. RESULTS Forty-six patients (47 knees) were included at a mean follow-up time of 6.6 years (SD 4.6; range 1-17). Mean BPII 2.0 score was 60.4 (SD 18.4; range 26-98), and 10.6% (n = 5) had suffered a postoperative redislocation. Progression to evident patellofemoral OA was seen in 15% of the patients (p < 0.05). The presence of pathoanatomic risk factors did not correlate with recurrent postoperative instability or inferior BPII 2.0 score at the final evaluation. CONCLUSION Patients treated with the current approach reported acceptable medium- to long-term results, but the risk of patellofemoral OA progression is significant. These findings add to the knowledge of expected outcomes after procedures involving Insall proximal realignment, and can guide clinical decision making for surgeons using similar methods. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Per Arne Skarstein Waaler
- Department of Orthopaedic Surgery, Førde Health Thrust, Førde Central Hospital, Svanehaugvegen 2, 6812, Førde, Norway.
| | - Truls Jellestad
- Department of Orthopaedic Surgery, Førde Health Thrust, Lærdal Hospital, Førde, Norway
| | - Trine Hysing-Dahl
- Department of Rehabilitation, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Elise Elvehøy
- Department of Physiotherapy, Førde Health Thrust, Lærdal Hospital, Førde, Norway
| | - Eivind Inderhaug
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Milinkovic DD, Fink C, Kittl C, Sillanpää P, Herbst E, Raschke MJ, Herbort M. Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study. Am J Sports Med 2021; 49:1827-1838. [PMID: 33960859 DOI: 10.1177/03635465211009540] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. PURPOSE To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft's application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. RESULTS The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. CONCLUSION The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. CLINICAL RELEVANCE Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.
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Affiliation(s)
| | - Christian Fink
- Gelenkpunk-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Petri Sillanpää
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Pihlajalinna Koskisairaala Hospital, Tampere, Finland
| | | | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,OCM Orthopedic Surgery Munich Clinic, Munich, Germany
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13
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Alvarez O, Steensen RN, Rullkoetter PJ, Fitzpatrick CK. Computational approach to correcting joint instability in patients with recurrent patellar dislocation. J Orthop Res 2020; 38:768-776. [PMID: 31736122 DOI: 10.1002/jor.24526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 11/10/2019] [Indexed: 02/04/2023]
Abstract
Patellar dislocation is a debilitating injury common in active adolescents and young adults. Conservative treatment after initial dislocation is often recommended, but almost half of these patients continue to suffer from recurrent dislocation. The objective of this study was to compare preoperative patellofemoral joint stability with stability after a series of simulated procedures, including restorative surgery to correct to pre-injury state, generic tibial tubercle osteotomy, patient-specific reconstructive surgery to correct anatomic abnormality, less invasive patient-specific surgery, and equivalent healthy controls. Three-dimensional, subject-specific finite element models of the patellofemoral joint were developed for 28 patients with recurrent patellar dislocation. A 50 N lateral load was applied to the patella to assess the lateral stability of the patellofemoral joint at 10° intervals from 0° to 40° flexion. Medial patellofemoral ligament reconstruction, along with reconstructive procedures to correct anatomic abnormality were simulated. Of all the simulations performed, the healthy equivalent control models showed the least patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament restraining load during lateral loading tests. Isolated restorative medial patellofemoral ligament reconstruction was the surgery that resulted in the most patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament reaction force across all flexion angles. Patient-specific reconstruction to correct anatomic abnormality was the only surgical group to have non-significantly different results compared with the healthy equivalent control group across all joint stability metrics evaluated. Statement of clinical significance: This study suggests patient-specific reconstructive surgery that corrects underlying anatomic abnormalities best reproduces the joint stability of an equivalent healthy control when compared with the pre-injury state, generic tibial tubercle osteotomy, and less invasive patient-specific surgery. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:768-776, 2020.
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Affiliation(s)
- Oliver Alvarez
- Mechanical and Biomedical Engineering, Boise State University, Boise, Idaho
| | | | - Paul J Rullkoetter
- Center for Orthopaedic Biomechanics, University of Denver, Denver, Colorado
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Ferrua P, Kruckeberg BM, Pasqualotto S, Berruto M, Randelli P, Arendt EA. Proximal medial patellar restraints and their surgical reconstruction. J Orthop Traumatol 2019; 20:17. [PMID: 30915690 PMCID: PMC6435766 DOI: 10.1186/s10195-019-0525-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/08/2019] [Indexed: 01/27/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.
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Affiliation(s)
- Paolo Ferrua
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Bradley M Kruckeberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Stefano Pasqualotto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Massimo Berruto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Pietro Randelli
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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LaPrade MD, Kallenbach SL, Aman ZS, Moatshe G, Storaci HW, Turnbull TL, Arendt EA, Chahla J, LaPrade RF. Biomechanical Evaluation of the Medial Stabilizers of the Patella. Am J Sports Med 2018; 46:1575-1582. [PMID: 29554436 DOI: 10.1177/0363546518758654] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantification of the biomechanical properties of each individual medial patellar ligament will facilitate an understanding of injury patterns and enhance anatomic reconstruction techniques by improving the selection of grafts possessing appropriate biomechanical properties for each ligament. PURPOSE To determine the ultimate failure load, stiffness, and mechanism of failure of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), and medial patellomeniscal ligament (MPML) to assist with selection of graft tissue for anatomic reconstructions. STUDY DESIGN Descriptive laboratory study. METHODS Twenty-two nonpaired, fresh-frozen cadaveric knees were dissected free of all soft tissue structures except for the MPFL, MPTL, and MPML. Two specimens were ultimately excluded because their medial structure fibers were lacerated during dissection. The patella was obliquely cut to test the MPFL and the MPTL-MPML complex separately. To ensure that the common patellar insertion of the MPTL and MPML was not compromised during testing, only one each of the MPML and MPTL were tested per specimen (n = 10 each). Specimens were secured in a dynamic tensile testing machine, and the ultimate load, stiffness, and mechanism of failure of each ligament (MPFL = 20, MPML = 10, and MPTL = 10) were recorded. RESULTS The mean ± SD ultimate load of the MPFL (178 ± 46 N) was not significantly greater than that of the MPTL (147 ± 80 N; P = .706) but was significantly greater than that of the MPML (105 ± 62 N; P = .001). The mean ultimate load of the MPTL was not significantly different from that of the MPML ( P = .210). Of the 20 MPFLs tested, 16 failed by midsubstance rupture and 4 by bony avulsion on the femur. Of the 10 MPTLs tested, 9 failed by midsubstance rupture and 1 by bony avulsion on the patella. Finally, of the 10 MPMLs tested, all 10 failed by midsubstance rupture. No significant difference was found in mean stiffness between the MPFL (23 ± 6 N/mm2) and the MPTL (31 ± 21 N/mm2; P = .169), but a significant difference was found between the MPFL and the MPML (14 ± 8 N/mm2; P = .003) and between the MPTL and MPML ( P = .028). CONCLUSION The MPFL and MPTL had comparable ultimate loads and stiffness, while the MPML had lower failure loads and stiffness. Midsubstance failure was the most common type of failure; therefore, reconstruction grafts should meet or exceed the values reported herein. CLINICAL RELEVANCE For an anatomic medial-sided knee reconstruction, the individual biomechanical contributions of the medial patellar ligamentous structures (MPFL, MPTL, and MPML) need to be characterized to facilitate an optimal reconstruction design.
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Affiliation(s)
| | | | - Zachary S Aman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, USA.,Oslo University Hospital and University of Oslo, Oslo, Norway.,Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway
| | | | | | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota Minneapolis, Minnesota, USA
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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