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Ferreira B, Gomes E, Figueiredo I, Ribeiro R, Valente C, Delgado D, Sánchez M, Andrade R, Espregueira-Mendes J. Derotational high tibial osteotomy in cases of anterior knee pain and/or patellofemoral instability: a systematic review. J ISAKOS 2024; 9:401-409. [PMID: 38430984 DOI: 10.1016/j.jisako.2024.02.015] [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: 12/18/2023] [Revised: 02/09/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
IMPORTANCE Derotational high tibial osteotomy (HTO) is a surgical intervention for correcting rotational malalignments in the lower limb, which may contribute to anterior knee pain (AKP) and/or patellofemoral instability (PFI). This surgical technique is not yet widely implemented and requires a systematic evaluation of its outcomes. AIM To assess the effectiveness of derotational HTO in correcting rotational malalignments of the lower limb in patients with AKP and/or PFI through radiological, clinical, and patient-reported outcome measures. EVIDENCE REVIEW Searches were conducted in the PubMed, Embase, and Web of Science databases up to March 3, 2023, to identify studies utilizing derotational HTO in patients with AKP and/or PFI. The primary outcome measures of interest were measurements of lower limb angular correction. Other radiological, clinical, and patient-reported outcome measures were also analyzed. The risk of bias was judged with the RoBANS tool. FINDINGS A total of 8 studies were included, comprising 215 patients (27.0 ± 3.9 years) and 245 knees. The most reported angle was tibial torsion (k = 6 studies, n = 173 knees), with a mean difference between postoperative and preoperative values (postsurgical correction) ranging from -37.8° to -10.8°. Patient-reported outcome measures showed significant improvements in the postoperative moment, exceeding the minimal clinically important difference in almost all cases, and with high patient satisfaction (93.6%). CONCLUSIONS AND RELEVANCE Derotational HTO allows the correction of rotational malalignments of the lower limb (tibial torsion) and promotes patient satisfaction. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Eluana Gomes
- Clínica Espregueira-FIFA Medical Centre of Excellence, 4350-415, Porto, Portugal
| | - Inês Figueiredo
- School of Medicine, Minho University, 4710-057, Braga, Portugal
| | - Ricardo Ribeiro
- School of Medicine, Minho University, 4710-057, Braga, Portugal
| | - Cristina Valente
- Clínica Espregueira-FIFA Medical Centre of Excellence, 4350-415, Porto, Portugal; Dom Henrique Research Centre, 4350-415, Porto, Portugal
| | - Diego Delgado
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, 01008, Vitoria-Gasteiz, Spain
| | - Mikel Sánchez
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, 01008, Vitoria-Gasteiz, Spain; Arthroscopic Surgery Unit, Hospital Vithas Vitoria, 01008, Vitoria-Gasteiz, Spain
| | - Renato Andrade
- Clínica Espregueira-FIFA Medical Centre of Excellence, 4350-415, Porto, Portugal; Dom Henrique Research Centre, 4350-415, Porto, Portugal; Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports, University of Porto, 4200-450, Porto, Portugal
| | - João Espregueira-Mendes
- School of Medicine, Minho University, 4710-057, Braga, Portugal; Clínica Espregueira-FIFA Medical Centre of Excellence, 4350-415, Porto, Portugal; Dom Henrique Research Centre, 4350-415, Porto, Portugal; ICVS/3B's-PT Government Associate Laboratory, 4710-057, Braga/Guimarães, Portugal; 3B's Research Group-Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4806-909, Barco, Guimarães, Portugal.
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Nagawa K, Inoue K, Hara Y, Shimizu H, Tsuchihashi S, Matsuura K, Kozawa E, Sugita N, Niitsu M. Three-dimensional magnetic resonance imaging-based statistical shape analysis and machine learning-based prediction of patellofemoral instability. Sci Rep 2024; 14:11390. [PMID: 38762569 PMCID: PMC11102474 DOI: 10.1038/s41598-024-62143-7] [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: 12/19/2023] [Accepted: 05/14/2024] [Indexed: 05/20/2024] Open
Abstract
This study performed three-dimensional (3D) magnetic resonance imaging (MRI)-based statistical shape analysis (SSA) by comparing patellofemoral instability (PFI) and normal femur models, and developed a machine learning (ML)-based prediction model. Twenty (19 patients) and 31 MRI scans (30 patients) of femurs with PFI and normal femurs, respectively, were used. Bone and cartilage segmentation of the distal femurs was performed and subsequently converted into 3D reconstructed models. The pointwise distance map showed anterior elevation of the trochlea, particularly at the central floor of the proximal trochlea, in the PFI models compared with the normal models. Principal component analysis examined shape variations in the PFI group, and several principal components exhibited shape variations in the trochlear floor and intercondylar width. Multivariate analysis showed that these shape components were significantly correlated with the PFI/non-PFI distinction after adjusting for age and sex. Our ML-based prediction model for PFI achieved a strong predictive performance with an accuracy of 0.909 ± 0.015, and an area under the curve of 0.939 ± 0.009 when using a support vector machine with a linear kernel. This study demonstrated that 3D MRI-based SSA can realistically visualize statistical results on surface models and may facilitate the understanding of complex shape features.
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Affiliation(s)
- Keita Nagawa
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan.
| | - Kaiji Inoue
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan.
| | - Yuki Hara
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Hirokazu Shimizu
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Saki Tsuchihashi
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Koichiro Matsuura
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Naoki Sugita
- Department of Orthopedics, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Mamoru Niitsu
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-Machi, Iruma-Gun, Saitama, Japan
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Ayala SG, Thomas N, Rohde M, Gupta A, Sanchez M, Tompkins M, Parikh SN, Ellis HB, Green DW, Yen YM, Fabricant PD, Wilson P, Shea KG. Osseous and Cartilaginous Trochlear Development in the Pediatric Knee: A Cadaveric Computed Tomography Study. Orthop J Sports Med 2024; 12:23259671241249132. [PMID: 38751851 PMCID: PMC11095196 DOI: 10.1177/23259671241249132] [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: 10/28/2023] [Accepted: 11/13/2023] [Indexed: 05/18/2024] Open
Abstract
Background The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design Descriptive laboratory study. Methods A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint.
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Affiliation(s)
- Salvador G. Ayala
- University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Nicholas Thomas
- Florida State University College of Medicine, Pensacola, Florida, USA
| | - Matthew Rohde
- Stanford School of Medicine, Stanford, California, USA
| | - Anshal Gupta
- Stanford School of Medicine, Stanford, California, USA
| | - Mark Sanchez
- Stanford School of Medicine, Stanford, California, USA
| | - Marc Tompkins
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Shital N. Parikh
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Henry B. Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | - Yi-Meng Yen
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | | | - Phil Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - Kevin G. Shea
- Stanford School of Medicine, Stanford, California, USA
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Barbosa RM, Serrador L, da Silva MV, Macedo CS, Santos CP. Knee landmarks detection via deep learning for automatic imaging evaluation of trochlear dysplasia and patellar height. Eur Radiol 2024:10.1007/s00330-024-10596-9. [PMID: 38337072 DOI: 10.1007/s00330-024-10596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVES To develop and validate a deep learning-based approach to automatically measure the patellofemoral instability (PFI) indices related to patellar height and trochlear dysplasia in knee magnetic resonance imaging (MRI) scans. METHODS A total of 763 knee MRI slices from 95 patients were included in the study, and 3393 anatomical landmarks were annotated for measuring sulcus angle (SA), trochlear facet asymmetry (TFA), trochlear groove depth (TGD) and lateral trochlear inclination (LTI) to assess trochlear dysplasia, and Insall-Salvati index (ISI), modified Insall-Salvati index (MISI), Caton Deschamps index (CDI) and patellotrochlear index (PTI) to assess patellar height. A U-Net based network was implemented to predict the landmarks' locations. The successful detection rate (SDR) and the mean absolute error (MAE) evaluation metrics were used to evaluate the performance of the network. The intraclass correlation coefficient (ICC) was also used to evaluate the reliability of the proposed framework to measure the mentioned PFI indices. RESULTS The developed models achieved good accuracy in predicting the landmarks' locations, with a maximum value for the MAE of 1.38 ± 0.76 mm. The results show that LTI, TGD, ISI, CDI and PTI can be measured with excellent reliability (ICC > 0.9), and SA, TFA and MISI can be measured with good reliability (ICC > 0.75), with the proposed framework. CONCLUSIONS This study proposes a reliable approach with promising applicability for automatic patellar height and trochlear dysplasia assessment, assisting the radiologists in their clinical practice. CLINICAL RELEVANCE STATEMENT The objective knee landmarks detection on MRI images provided by artificial intelligence may improve the reproducibility and reliability of the imaging evaluation of trochlear anatomy and patellar height, assisting radiologists in their clinical practice in the patellofemoral instability assessment. KEY POINTS • Imaging evaluation of patellofemoral instability is subjective and vulnerable to substantial intra and interobserver variability. • Patellar height and trochlear dysplasia are reliably assessed in MRI by means of artificial intelligence (AI). • The developed AI framework provides an objective evaluation of patellar height and trochlear dysplasia enhancing the clinical practice of the radiologists.
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Affiliation(s)
- Roberto M Barbosa
- Center of MicroElectroMechanical Systems (CMEMS), University of Minho, Guimarães, Portugal.
- MIT Portugal Program, School of Engineering, University of Minho, Guimarães, Portugal.
| | - Luís Serrador
- Center of MicroElectroMechanical Systems (CMEMS), University of Minho, Guimarães, Portugal
| | | | | | - Cristina P Santos
- Center of MicroElectroMechanical Systems (CMEMS), University of Minho, Guimarães, Portugal
- LABBELS - Associate Laboratory, Braga/Guimarães, Portugal
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Martinez-Cano JP, Gobbi RG, Giglio PN, Arendt E, Costa GB, Hinckel BB. Magnetic resonance imaging overestimates patellar height compared with radiographs. Knee Surg Sports Traumatol Arthrosc 2022; 30:3461-3469. [PMID: 35357529 DOI: 10.1007/s00167-022-06953-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the inter-observer and inter-method reliability for patellar height measurements between conventional radiographs (CR) and magnetic resonance imaging (MRI) using one or two slices. METHODS This was a reliability study, with 60 patients divided in two groups: 30 patients with patellar instability (patella group) and 30 patients with anterior cruciate ligament or meniscus injury (control group). CR and MRI were evaluated by two independent observers. Insall-Salvati index (IS) and Caton-Deschamps index (CD) were measured using three different methods: CR, one-slice MRI or two-slice MRI. Intra-class correlation coefficients (ICC) were calculated for inter-observer reliability and inter-method reliability. Bland-Altman agreement was also calculated. RESULTS The inter-observer reliability was very good for the IS with ICCs of 0.93, 0.84 and 0.82, for the CR, one-slice MRI and two-slice MRI, respectively. Similarly, for the CD the ICCs were good, 0.76, 0.80 and 0.75 for the CR, one-slice MRI and two-slice MRI, respectively. No differences were found between the patella and the control group. The inter-method analysis results were: ICCs for IS (0.83, 0.86, 0.93) and CD (0.72, 0.82, 0.83), for the comparisons of CR/one-slice MR, CR/two-slice MRI and one-slice MRI/two-slice MRI, respectively. The Bland-Altman mean differences showed an 8% and a 7% increase on IS values with one-slice MRI and two-slice MRI compared to CR results, while the increase was of 9% and 1% in CD for the respective comparisons with CR. CONCLUSION MRI can overestimate patellar height compared to CR, as much as an 8% increase in Insall-Salvati values when using one- or two-slice MRI measurements, and up to a 9% increase in Caton-Deschamps value when using the one-slice MRI method. It is recommended to use the CR as the preferred method when measuring patellar height. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Faculdade de Medicina, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Faculdade de Medicina, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
| | - Elizabeth Arendt
- Department of Orthopaedic Surgery, Medical School, University of Minnesota, Minneapolis, USA
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
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Ahrend MD, Eisenmann T, Herbst M, Gueorguiev B, Keller G, Schmidutz F, Döbele S, Schröter S, Ihle C. Increased tibial tubercle-trochlear groove and patellar height indicate a higher risk of recurrent patellar dislocation following medial reefing. Knee Surg Sports Traumatol Arthrosc 2022; 30:1404-1413. [PMID: 34032867 PMCID: PMC9007812 DOI: 10.1007/s00167-021-06581-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 04/13/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Identifying anatomical risk factors on recurrent dislocation after medial reefing is important for deciding surgical treatment. The present study aimed to retrospectively analyze the preoperative magnetic resonance imaging (MRI)-based parameters of patients treated with medial reefing and whether these parameters lead to a higher risk of recurrent dislocation. METHODS Fifty-five patients (18.6 ± 6.6 years) who underwent medial reefing after primary traumatic patellar dislocation (84% with medial patellofemoral ligament [MPFL] rupture) were included. Patients were followed up for at least 24 months postoperatively (3.8 ± 1.2 years) to assess the incidence of recurrent patellar dislocation. In patients without recurrent dislocation, the Kujala and subjective IKDC scores were assessed. Moreover, the tibial tubercle-trochlear groove (TT-TG), sulcus angle, patellar tilt, patellar shift, and lateral trochlea index (LTI) were measured. The patellar height was measured using the Caton-Dechamps (CDI), Blackburne-Peel (BPI), and Insall-Salvati index (ISI). The cohort was subclassified into two groups with and without recurrent dislocation. Differences between groups were analyzed with respect to the MRI parameters. RESULTS Forty percent had a pathological sulcus angle of > 145°, 7.2% had an LTI of < 11°, 47.3% had a patellar tilt of > 20°, and 36.4% had a TT-TG of ≥ 16 mm. Increased patellar height was observed in 34.5, 65.5, and 34.5% of the patients as per CDI, BPI, and ISI, respectively. Nineteen (34.5%) patients suffered from recurrent dislocation. Compared with patients without recurrent dislocation, those with recurrent dislocation had a significantly lower LTI (p = 0.0467). All other parameters were not significantly different between the groups. Risk factor analysis showed higher odds ratios (OR > 2), although not statistically significant, for MPFL rupture (OR 2.05 [95% confidence interval 0.38-11.03], LTI (6.6 [0.6-68.1]), TT-TG (2.9 [0.9-9.2]), and patellar height according to ISI (2.3 [0.7-7.5]) and CDI (2.3 [0.7-7.5])). Patients without recurrent dislocation had a Kujala score of 93.7 ± 12.1 (42-100) points and an IKDC score of 90.6 ± 11.7 (55.2-100) points. CONCLUSION Anatomical, MRI-based parameters should be considered before indicating medial reefing. A ruptured MPFL, an LTI < 11°, a TT-TG ≥ 16 mm, a patellar tilt > 20 mm, and an increased patellar height according to ISI and CDI were found to be associated, although not significantly, with a higher risk (OR > 2) of recurrent patellar dislocation after medial reefing. Thorough preoperative analysis is crucial to reduce the risk of recurrent dislocation in young patient cohorts. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Marc-Daniel Ahrend
- grid.10392.390000 0001 2190 1447Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany ,grid.418048.10000 0004 0618 0495AO Research Institute Davos, Davos, Switzerland
| | - Tobias Eisenmann
- grid.10392.390000 0001 2190 1447Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Moritz Herbst
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Boyko Gueorguiev
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Davos, Switzerland
| | - Gabriel Keller
- grid.411544.10000 0001 0196 8249Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tübingen, Germany
| | - Florian Schmidutz
- grid.10392.390000 0001 2190 1447Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Döbele
- grid.10392.390000 0001 2190 1447Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Steffen Schröter
- grid.491771.dDepartment of Traumatology and Reconstructive Surgery, Diakonie Klinikum GmbH Jung-Stilling-Krankenhaus, Siegen, Germany
| | - Christoph Ihle
- grid.10392.390000 0001 2190 1447Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
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Pagliazzi G, Ellermann JM, Carlson CS, Shea KG, Arendt EA. Trochlear Development in Children From 1 Month to 10 Years of Age: A Descriptive Study Utilizing Analysis by Magnetic Resonance Imaging. Orthop J Sports Med 2021; 9:23259671211028269. [PMID: 34552991 PMCID: PMC8450999 DOI: 10.1177/23259671211028269] [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: 01/22/2021] [Accepted: 02/24/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Understanding the morphology of cartilage/bony maturation in preadolescents may help explain adult trochlear variation. PURPOSE To study trochlear morphology during maturation in children and infants using magnetic resonance imaging (MRI). STUDY DESIGN Descriptive laboratory study. METHODS Twenty-four pediatric cadaveric knees (10 male and 14 female knees; age, 1 month to 10 years) were included. High-resolution imaging of the distal femoral secondary ossification center was performed using 7-T or 9.4-T MRI scanners. Three-dimensional MRI scans were produced, and images were reformatted; 3 slices in the axial, sagittal, and coronal planes images were analyzed, with coronal and sagittal imaging used for image orientation. Biometric analysis included lateral and medial trochlear height (TH); cartilaginous sulcus angle (CSA); osseous sulcus angle (OSA); trochlear depth; and trochlear facet (TF) length symmetry. Sex comparisons were considered when ≥1 specimen from both sexes of the same age was available; these included 11 knees spanning 4 age groups (ages 1, 3, 4, and 7 years). RESULTS The analysis of trochlear morphology showed a lateral TH greater than the medial TH at all ages. The thickest cartilage was found on the lateral TF in the younger specimens. Regarding the development of osseous and cartilaginous trochlear contour, a cartilaginous sulcus was present in the 3-month-old specimen and continued to deepen up to the age of 4 years. The shape of the osseous center evolved from round (1 month) to oval (9 months) to rectangular (2 years); no distinct bony trochlear sulcus was present, although a well-formed cartilaginous sulcus was present. The first evidence of formation of a bony sulcus was at 4 years. By the age of 7 to 8 years, the bony contour of the adult distal femur resembled its cartilaginous contour. Female samples had a shallower CSA and OSA than did the male ones in all samples that had a defined OSA. CONCLUSION Female trochlear grooves tended to be shallower (flatter). The lateral trochlea was higher (TH) and wider (TF length) during growth than was the medial trochlea in both sexes; furthermore, the development of the osseous sulcus shape lagged behind the development of the cartilaginous sulcus shape in the authors' study population. CLINICAL RELEVANCE Bony anatomy of the trochlear groove did not match the cartilaginous anatomy in preadolescent children, suggesting that caution should be used when interpreting bony anatomy in this age group.
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Affiliation(s)
- Gherardo Pagliazzi
- Rizzoli Orthopaedic Institute, Bologna, Italy
- Lugano Regional Hospital, Lugano, Switzerland
| | - Jutta M. Ellermann
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cathy S. Carlson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kevin G. Shea
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Elizabeth A. Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Zikria B, Rinaldi J, Guermazi A, Haj-Mirzaian A, Pishgar F, Roemer FW, Hakky M, Sereni C, Demehri S. Lateral patellar tilt and its longitudinal association with patellofemoral osteoarthritis-related structural damage: Analysis of the osteoarthritis initiative data. Knee 2020; 27:1971-1979. [PMID: 33248351 DOI: 10.1016/j.knee.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/03/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Increase in lateral patellar tilt-(LPT) can cause increased pressure on the lateral facet of the knee and can lead to patellar or femoral cartilage damage and further osseous changes. This study aims to test the hypothesis whether there is an association between increased LPT and MRI-based patellofemoral osteoarthritis-(OA) features at baseline and their worsening over a 2-year follow-up in participants of the Osteoarthritis Initiative-(OAI). METHODS Recorded clinical and imaging data of 600 participants in the FNIH-OA biomarkers consortium was extracted from its database. The LPT-(as the angle betweenthe longest patella diameter and posterior aspect of condyles) was measured using theaxial knee MRI. Associations of LPT (every 5° increase) with MRI OA Knee Scoring-(MOAKS) for OA-related features, including cartilage and bone marrow lesions (BMLs) in addition to knee cartilage volume at baseline and their worsening after 2-year follow-up were assessed using regression models adjusted for several possible confounders. RESULTS The mean LPT angle in this sample was 8.84° ± 5.19. In baseline, higher LPT was associated with lower cartilage volumes and higher cartilage lesions and BMLs MOAKS scores in the lateral trochlear and patellar subregions. Over the follow-ups, subjects with higher LPT measures in the baseline showed higher odds of experiencing BML score worsening in the lateral trochlear subregion-(OR:1.25[1.01-1.56]) over the 2-year follow-ups. CONCLUSIONS Increase in LPT measures may be associated with OA-related features in the trochlear subregion. Therefore, aside from its use as an indicator of patellofemoral instability syndrome, LPT may be associated with longitudinal progression of patellofemoral OA.
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Affiliation(s)
- Bashir Zikria
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA.
| | - Joseph Rinaldi
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Arya Haj-Mirzaian
- Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Farhad Pishgar
- Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Frank W Roemer
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA; Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg & Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michael Hakky
- Department of Radiology, Florida Hospital, Maitland, FL, USA
| | - Christopher Sereni
- Department of Radiology, University of Massachusetts Medical School, Boston, MA, USA
| | - Shadpour Demehri
- Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
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Leal A, Andrade R, Hinckel B, Tompkins M, Bastos R, Flores P, Samuel F, Espregueira-Mendes J, Arendt E. Patients with different patellofemoral disorders display a distinct ligament stiffness pattern under instrumented stress testing. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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A new device for patellofemoral instrumented stress-testing provides good reliability and validity. Knee Surg Sports Traumatol Arthrosc 2020; 28:389-397. [PMID: 31250058 DOI: 10.1007/s00167-019-05601-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the reliability of an instrumented patellofemoral (PF) stress-testing-the Porto Patellofemoral Testing Device (PPTD)-and validate the instrumented assessment method comparing to manual physical examination. METHODS Eight asymptomatic volunteers underwent bilateral PF-instrumented examination with the PPTD and magnetic resonance imaging (MRI) to assess intra-rater reliability of the instrumented assessment methodology. Six patients with unilateral PF instability underwent physical examination and PPTD concomitantly with MRI. Manual examination was performed by two blinded surgeons and compared with PPTD test. Ligament stiffness was calculated and compared between injured and non-injured lower limbs. RESULTS PPTD showed a pre-determined and reproducible stress-force application with excellent intra-rater agreement (intra-class correlation coefficient 0.83-0.98). The manual exam was imprecise with variable examiner-dependent stress-force application. The PPTD resulted in greater lateral patellar translation (converted in quadrants) than manual exam for patients that have reached maximum translation force. Measurement of patellar position and displacement using PPTD was more accurate and precise than the visual estimation of translated quadrants by manual exam. Ligament stiffness curves showed no relevant changes in patellar displacement after 62 N. CONCLUSION The PPTD instrumented stress-testing is a valid device to quantify PF position and displacement with high intra-rater reliability, showing more accuracy, more precision and less variability than physical examination. This device provides an accurate and objective measure to quantify the patellar movement which can augment the physical examination procedures and assist clinicians in the management of decision-making and in the assessment of post-treatment outcomes of PF pathological conditions.
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Ambra LF, Hinckel BB, Arendt EA, Farr J, Gomoll AH. Anatomic Risk Factors for Focal Cartilage Lesions in the Patella and Trochlea: A Case-Control Study. Am J Sports Med 2019; 47:2444-2453. [PMID: 31287712 DOI: 10.1177/0363546519859320] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Focal cartilage lesions in the patellofemoral (PF) joint are common. Several studies correlated PF risk factors with PF instability, anterior knee pain, and PF arthritis; however, there is a lack of evidence correlating those factors to PF focal cartilage lesions. PURPOSE To evaluate the influence of the anatomic PF risk factors in patients with isolated focal PF cartilage lesions. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Patients with isolated PF focal cartilage lesions were included in the cartilage lesion group, and patients with other pathologies and normal PF cartilage were included in the control group. Multiple PF risk factors were accessed on magnetic resonance imaging scans: patellar morphology (patellar width, patellar thickness, and patellar angle), trochlear morphology (trochlear sulcus angle, lateral condyle index, and trochlear sulcus depth), patellar height (Insall-Salvati ratio and Caton-Deschamps index), axial patellar positioning (patellar tilt, angle of Fulkerson), and quadriceps vector (tibial tuberosity-trochlear groove distance). RESULTS A total of 135 patients were included in the cartilage lesion group and 100 in the control group. As compared with the control group, the cartilage lesion group had a higher sulcus angle (P = .0007), lower trochlear sulcus depth (P < .0001), lower angle of Fulkerson (P < .0001), lower patellar width (P = .0003), and higher Insall-Salvati ratio (P < .0001). From the patients in the cartilage lesion group, 36% had trochlear dysplasia; 27.6%, patella alta; and 24.7%, abnormal patellar tilt. These parameters were more frequent in the cartilage lesion group (P < .0001). Trochlear lesions were more frequent in men, presented at an older age, and had fewer associated anatomic risk factors. Patellar lesions, conversely, were more frequent in women, presented at younger age, and were more closely associated with anatomic risk factors. CONCLUSION PF anatomic abnormalities are significantly more common in patients with full-thickness PF cartilage lesions. Trochlear dysplasia, patella alta, and excessive lateral patellar tilt are the most common correlated factors, especially in patellar lesions.
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Affiliation(s)
- Luiz Felipe Ambra
- Universidade Federal de São Paulo Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina/UNIFESP, São Paulo, Brazil.,Center for Regenerative Medicine and Center of Cartilage Repair, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Betina B Hinckel
- Department of Orthopedic Surgery, Brigham and Women's Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jack Farr
- School of Medicine, Indiana University, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, Indiana, USA
| | - Andreas H Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Tibial Tubercle-Trochlear Groove Distance Is a Reliable and Accurate Indicator of Patellofemoral Instability. Clin Orthop Relat Res 2019; 477:1450-1458. [PMID: 31094842 PMCID: PMC6554121 DOI: 10.1097/corr.0000000000000711] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial tubercle-trochlear groove (TT-TG) distance is a measurement generally made on CT scans that is commonly used to quantify the risk of patellofemoral instability (PFI); however, its interrater reliability and accuracy as an indicator of PFI in patients is poorly characterized. QUESTIONS/PURPOSES The purposes of our study were (1) to primarily analyze interrater reliability of the TT-TG distance among orthopaedists with varied experience as measured by MRI, (2) to secondarily compare TT-TG distances between PFI and control groups, and (3) to determine an accurate TT-TG distance threshold indicative of PFI. METHODS The electronic medical records of a senior fellowship-trained orthopaedic sports medicine surgeon were surveyed between 2012 and 2016 for patients who had experienced at least one episode of patellar subluxation or dislocation, who reported no other knee-related history, and who underwent MRI due to persistent PFI signs and symptoms. The records of 48 PFI patients (23 males, 25 females; 19 ± 4 years of age) were compared with 83 controls (60 males, 23 females; 31 ± 8 years of age) having no history of PFI, presenting with an isolated meniscal lesion as determined from MRI and treated by the same orthopaedist during this time. All records meeting study criteria were consecutively included to offset selection bias of the retrospective analysis. Two sports medicine fellows, one who had just completed orthopaedic residency training, and another with a year of experience after residency, and a sports medicine subspecialist with more than 15 years of experience in practice independently recorded TT-TG distance, indicative of tibial tubercle lateralization relative to the femoral trochlea, to the nearest millimeter (mm) in a blinded and randomized fashion. Intraclass correlation coefficient computed interrater reliability accompanied by standard error of measurement (SEM); a one-tailed, two-sample t-test analyzed group differences with accompanying effect size per Cohen's d; receiver operating characteristic (ROC) curve determined accuracy and threshold for PFI risk. A p value < 0.05 denoted statistical significance. RESULTS Interrater reliability was excellent, at 0.93 (95% confidence interval [CI], 0.84-0.97; SEM = 0.6 mm) for PFI patients and 0.95 (95% CI, 0.91-0.97; SEM = 0.4 mm) for controls. Distance was greater (95% CI, 2-5; p < 0.001) in PFI patients (14 ± 4 mm; range = 7-24 mm) than controls (10 ± 3 mm; range = 3-19 mm) with an effect size of 1 (95% CI, 0.3-2). Area under the ROC curve was 0.75 (95% CI, 0.66-0.83) and threshold was 13 mm (sensitivity = 0.52, 1-specificity = 0.25), suggesting the measure is a fairly accurate indicator of risk and values of 13 mm or greater are better suited to rule in PFI. Respective positive and negative likelihood ratios of 2 and 0.6 at this threshold confirm that this distance yields a small increase in probability for PFI and a minimal decrease in probability for risk; specifically, a 13-mm TT-TG distance is two times more likely to be found in patients with PFI. Furthermore, this threshold is estimated to increase a correct PFI diagnosis by approximately 15%. CONCLUSIONS The MRI-specific TT-TG distance, based on a single measurement using cartilaginous-tendon landmarks within a standardized trochlear range, is reliable as performed by orthopaedists of varied experience. Patients with PFI display a 4-mm greater distance than controls, which may represent a difference large enough for clinicians to discern in practice using MRI. A 13-mm TT-TG distance is two times more likely seen in patients with PFI. However, this threshold increases a correct PFI diagnosis by only about 15%; therefore, clinical decision-making should not be influenced by this criterion alone and instead used in conjunction with other relevant variables. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Arendt EA, Askenberger M, Agel J, Tompkins MA. Risk of Redislocation After Primary Patellar Dislocation: A Clinical Prediction Model Based on Magnetic Resonance Imaging Variables. Am J Sports Med 2018; 46:3385-3390. [PMID: 30398902 DOI: 10.1177/0363546518803936] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND First-time lateral patellar dislocations have historically been treated with a nonoperative approach; a clinical tool to predict patients who are most likely to redislocate may have clinical utility. PURPOSE (1) To determine if there are discriminating factors present between patients who redislocated their patellas and those who did not after a first-time lateral patellar dislocation and (2) to use this information to develop a model that can predict the recurrence risk of lateral patellar dislocation in this population. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS The study population included those with first-time lateral patellar dislocation, magnetic resonance imaging within 6 weeks, and 2-year minimum follow-up. Cohort A was from a prospective study with 2-year follow-up. Cohort B was a prospectively identified cohort with retrospective chart review. Follow-up was obtained clinically or via mail for patients without 2-year clinical follow-up. RESULTS Sixty-one patients (42%) out of 145 with primary lateral patellar dislocation had recurrent dislocation within 2 years. Stepwise logistic regression analysis demonstrated that skeletal immaturity (odds ratio, 4.05; 95% CI, 1.86-8.82; P = .0004), sulcus angle (odds ratio, 4.87; 95% CI, 2.01-11.80; P = .0005), and Insall-Salvati ratio (odds ratio, 3.0; 95% CI, 1.34-6.70; P = .0074) were significant predictors of redislocation. Receiver operator characteristic curves defined the cut points to be sulcus angle ≥154° and Insall-Salvati ratio ≥1.3. The probability of redislocation based on the presence of factors was 5.8% with no factors present and 22.7% with any 1 factor present, increasing to 78.5% if all 3 factors were present. CONCLUSION This model demonstrates a high risk of lateral patellar redislocation when a patient presents with skeletal immaturity as well as magnetic resonance measurements of sulcus angle ≥154° and patellar height as measured by Insall-Salvati ratio ≥1.3. A patient will have a low risk of lateral patellar redislocation with the inverse findings.
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Affiliation(s)
- Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marie Askenberger
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Julie Agel
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- TRIA Orthopaedic Center, Bloomington, Minnesota, USA
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Tibial tuberosity to trochlear groove distance and its association with patellofemoral osteoarthritis-related structural damage worsening: data from the osteoarthritis initiative. Eur Radiol 2018; 28:4669-4680. [DOI: 10.1007/s00330-018-5460-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/22/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
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Hinckel BB, Gobbi RG, Kaleka CC, Camanho GL, Arendt EA. Medial patellotibial ligament and medial patellomeniscal ligament: anatomy, imaging, biomechanics, and clinical review. Knee Surg Sports Traumatol Arthrosc 2018; 26:685-696. [PMID: 28289819 DOI: 10.1007/s00167-017-4469-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/07/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this article is to review anatomical, biomechanical, and clinical data of the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML), as well as studies focusing on the medial patellofemoral ligament (MPFL) but with relevant data about the MPTL and MPML. METHODS A literature search of articles specifically addressing the MPTL and/or MPML was included along with studies focusing on the MPFL but with relevant data about the MPTL and MPML. RESULTS The medial patellar ligaments responsible for maintaining the stability of the patellofemoral (PF) joint include the MPFL, the MPTL, and the MPML. The MPFL is considered the primary restraint to lateral patellar translation, while the latter two are considered secondary restraints. There is robust literature on the anatomical, imaging, and biomechanical characteristics of the MPFL, and also the clinical outcome of its injury and surgical reconstruction; much less is known about the MPTL and MPML. Isolated MPFL reconstruction has good clinical and functional outcomes, with a low failure rate when defined as frank re-dislocation. Complications, including continued episodes of patellar apprehension and subluxation, remain present in most series. In addition, the current literature primarily includes a homogeneous population with few excessive anatomic dysplastic factors. There is lack of knowledge on the role of MPTL and MPML in (potentially) aiding patella stabilization and improving clinical outcomes. Understanding the role of the medial-sided patellar ligaments, in particular the role of the secondary stabilizers, in PF function and injury will aid in this goal. CONCLUSION MPTL and MPML have consistent basic science literature, as well as favorable clinical outcomes of surgical patellar stabilization with reconstruction of the MPTL. However, there is much heterogeneity among clinical case series and lack of comparative studies to allow clear indication for the role of isolated or combined surgical reconstruction in patellar stabilization. Therefore, this comprehensive review helps understand the current knowledge and the possible applications in the orthopedic clinical practice. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Betina Bremer Hinckel
- Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65212, USA
| | - Riccardo Gomes Gobbi
- Orthopedics and Traumatology Institute, University of Sao Paulo, Ovidio Pires de Campos St, 333, Sao Paulo, SP, 5403-010, Brazil
| | - Camila Cohen Kaleka
- Albert Einstein Israelite Hospital, Av Albert Einstein, 627, Building A1, unit 306, Sao Paulo, SP, 05652-900, Brazil
| | - Gilberto Luis Camanho
- Orthopedics and Traumatology Institute, University of Sao Paulo, Ovidio Pires de Campos St, 333, Sao Paulo, SP, 5403-010, Brazil
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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Arendt EA, Donell ST, Sillanpää PJ, Feller JA. The management of lateral patellar dislocation: state of the art. J ISAKOS 2017. [DOI: 10.1136/jisakos-2015-000011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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