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McNamara NE, Shing EZ, Khalil AZ, Tabish EM, Featherall JT, Rosenthal RM, Maak TG, Aoki SK, Ernat JJ. Tibial Tubercle Osteotomy With and Without Medial Patellofemoral Ligament Reconstruction in Adolescent Patients Leads to Decrease in Patellar Height and Patella Tendon Length. J Pediatr Orthop 2024:01241398-990000000-00596. [PMID: 38907594 DOI: 10.1097/bpo.0000000000002753] [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] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Patellar height changes after tibial tubercle osteotomy (TTO) have not yet been described. We aimed to evaluate whether TTO ± medial patellofemoral ligament reconstruction (MPFL-R) influences patellar height and tendon length, hypothesizing that TTO would decrease patellar height and tendon length. METHODS A retrospective review was performed of skeletally mature adolescents (<18 y) receiving primary anteromedialization or medialization TTO ± MPFL-R. Patients with at least 6 months of radiographic follow-up were included in the study. Pre and postoperative patellar heights were assessed on lateral, weight-bearing, and flexion (30 to 70 degrees) radiographs using the Blackburne-Peel Index (BPI), Caton-Deschamps Index (CDI), and Insall-Salvati Ratio (ISR). Subgroup analyses were performed to compare patellar height changes in patients with preoperative patella alta, norma, and baja, as well as between patients undergoing medialization and anteromedialization TTO. Data were analyzed for normality using a Shapiro-Wilk test, and paired-sample t tests were performed. RESULTS Forty-nine knees were included (mean age: 15 y; range: 12 to 17). A significant decrease in mean patellar height after TTO ± MPFL-R was observed across all measures: BPI (0.12, P = 0.000783), CDI (0.08, P = 0.01062), and ISR (0.15, P = 0.00000075). Patellar tendon length decreased by 2.26 mm ( P = 0.001272). Subgroup analyses demonstrated a decrease in mean patellar height across all 3 measurements ( P < 0.001; BPI, CDI, and ISR) for patients with preoperative patella alta but not patella norma or baja. Additional subgroup analysis showed a patellar height decrease using BPI (0.15, P = 0.004583) and ISR (0.14, P = 0.0002806) for patients receiving medialization TTO but not anteromedialization. The anteromedialization cohort did not demonstrate patellar height change using BPI and CDI; ISR demonstrated a decrease (0.10, P = 0.00917). CONCLUSIONS Mean patellar height and tendon length decreases after TTO ± MPFL-R in skeletally mature, adolescent patients. Subgroup analyses suggest these changes occur in patients with preoperative patella alta and/or patients who undergo medialization TTO. These data suggest that some distalization in patellar positioning may be achieved without formal distalization osteotomy.
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Affiliation(s)
- Natalya E McNamara
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Schneble CA, Yu K, Venkadesan M, Cooperman D, Beitler B, Sieberer J, Fulkerson J. Three-Dimensional Imaging of the Patellofemoral Joint Improves Understanding of Trochlear Anatomy and Pathology and Planning of Realignment. Arthroscopy 2024:S0749-8063(24)00305-0. [PMID: 38697330 DOI: 10.1016/j.arthro.2024.04.010] [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: 02/18/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 05/04/2024]
Abstract
Three-dimensional (3D) modeling using digital or printed models provides a unique perspective that caters to cognitive spatial ability in a way that can add to our understanding and mental representations of human anatomy. This is particularly useful in the setting of trochlear dysplasia, where the morphology of the groove can exhibit substantial variability and complexity. Using 3D reformatted images and models, a pragmatic understanding of how morphology influences patellofemoral pathology can be gleaned. Further, this perspective facilitates cognition of what patellar tracking may look like after realignment procedures. Using 3D modeling, concepts such as patella alta, trochlear depth, lateralization of the patellar entry point, trochlear curvature, and the presence of a proximal trochlear spur can help afford a better understanding of how trochlear anatomy may influence tracking while also providing insight as to the ideal tracking path. The use of 3D has recently emerged as a useful tool in multiple surgical subspecialties, particularly in situations involving surgical planning or complex anatomy. Given the complexity and variation in trochlear morphology in patients with trochlear dysplasia who develop either patellar instability or focal overloading, 3D modeling is well-suited to provide a perspective that can add to our understanding of trochlear dysplasia, and potentially even how we diagnose and treat it. LEVEL OF EVIDENCE: Level V, expert opinion.
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Affiliation(s)
- Christopher A Schneble
- Orthopedic Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Kristin Yu
- Orthopaedic Surgery, Mayo Clinic Foundation, Rochester, Minnesota, U.S.A
| | - Madhusudhan Venkadesan
- Department of Mechanical Engineering and Materials Science, Yale University, New Haven, Connecticut, U.S.A
| | - Daniel Cooperman
- Department of Orthopaedic Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Brian Beitler
- Orthopaedic Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Johannes Sieberer
- Department of Mechanical Engineering and Materials Science, Yale University, New Haven, Connecticut, U.S.A
| | - John Fulkerson
- Department of Orthopaedic Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A..
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Chamorro-Moriana G, Espuny-Ruiz F, Ridao-Fernández C, Magni E. Clinical value of questionnaires & physical tests for patellofemoral pain: Validity, reliability and predictive capacity. PLoS One 2024; 19:e0302215. [PMID: 38630735 PMCID: PMC11023591 DOI: 10.1371/journal.pone.0302215] [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: 12/22/2023] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES To determine the most appropriate method of functional assessment for "patellofemoral pain" (PFP)/"chondromalacia patella" for its diagnostic value, (validity, reliability, sensitivity, specificity, predictive value and clinical applicability); to outline initial interpretations of the questionnaires and their appropriateness, through the cut-off points determined in their scores based on physical test and Magnetic Resonance Imaging (MRI); to establish which methods should be used in conjunction with each other to obtain clinical diagnoses that are robust effective and efficient. METHODS (1)Intra- and inter-observer reliability and of the relationship among PFP questionnaires/physical tests validated. (2)Predictive capacity of the questionnaires. Subject: 113 knees with PFP, assessed using "Knee-injury-and-Osteoarthritis Outcome-Score-for-Patellofemoral-pain-and-osteoarthritis" (KOOS-PF), "Kujala-Patellofemoral-Score" (KPS), "Victorian-Institute-of-Sports-Assessment-for-Patellar-tendons-questionnaire" (VISA-P), and the physical tests: "patellar-palpation", "patellar-tilt", "patellar-apprehension", "Clarke" and "squat". RESULTS Questionnaires correlations themselves was 0.78 CONCLUSIONS KOOS-PF, KPS and VISA-P demonstrated their diagnostic value in PFP/chondromalacia (validity, reliability, sensitivity, specificity, predictive value and clinical applicability). KOOS-PF was the most versatile, and the most appropriate in mild cases and for early detection and prevention. Squat was the best due to its reliability and clinical relationship with the questionnaires, which predicted it correctly. The functional assessment tools discussed should be applied by combining them with each other.
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Affiliation(s)
- Gema Chamorro-Moriana
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
- Research Group “Area of Physiotherapy CTS305”, Spain
| | - Fernando Espuny-Ruiz
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
| | - Carmen Ridao-Fernández
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
- Research Group “Area of Physiotherapy CTS305”, Spain
| | - Eleonora Magni
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
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Shah AK, Uppstrom TJ, Rizy ME, Gomoll AH, Strickland SM. Incidence of Complications After Tibial Tubercle Osteotomy and Tibial Tubercle Osteotomy With Distalization. Am J Sports Med 2024; 52:1274-1281. [PMID: 38516864 DOI: 10.1177/03635465241235883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patellofemoral instability and pain. TTO with distalization (TTO-D) is indicated for patients with patellofemoral instability, patellar malalignment, and patella alta. The current literature demonstrates several complications that may be associated with TTO, with reportedly higher rates of complications associated with TTO-D. PURPOSE To analyze and compare complication rates after TTO without distalization (TTO-ND) and TTO-D and assess risk factors associated with complications. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All skeletally mature patients who underwent TTO with or without distalization by a single surgeon between September 2014 and May 2023 with a minimum of 6 months of clinical follow-up were retrospectively reviewed. Patient factors, surgical indications, perioperative data, and complications were collected via a retrospective review of electronic medical records. Concomitant procedures were categorized as intra-articular, extra-articular, and osteotomies. RESULTS A total of 251 TTOs (117 TTO-D, 134 TTO-ND) were included in the study group. Postoperative complications were observed in 15 operations (6%), with arthrofibrosis as the most common complication (10 operations [4%]). TTO-D and TTO-ND had similar rates of complication (5% vs 7%; P = .793). Clinical nonunion was observed in 3 operations (3%) in the TTO-D cohort and 1 operation (1%) in the TTO-ND cohort. In the TTO-D cohort, concomitant intra-articular procedures were significantly associated with an increased likelihood of complications in a univariate model. In the TTO-ND cohort, an increased tourniquet time was significantly associated with an increased likelihood of complications in a univariate model. For all TTOs as well as the TTO-D and TTO-ND cohorts, there were no significant associations between patient or surgical variables in a multivariate model. CONCLUSION TTO with and without distalization is a safe procedure with low rates of complication. TTO-D was not associated with a higher rate of complications compared with TTO-ND. There was no association between complications and surgical variables for TTO procedures.
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Affiliation(s)
- Aakash K Shah
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA
| | - Tyler J Uppstrom
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Morgan E Rizy
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Andreas H Gomoll
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Sabrina M Strickland
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
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Kreulen RT, Anderson G, Yalcin S, Hart JM, Shank K, Fury MS, Elias JJ, Tanaka MJ, Farrow LD, Diduch DR, Cosgarea AJ. Evaluation of Differences in Patellar Height After Patellar Stabilization Procedures Not Intended to Address Patella Alta: A Multicenter Study. Orthop J Sports Med 2024; 12:23259671241235597. [PMID: 38515605 PMCID: PMC10956155 DOI: 10.1177/23259671241235597] [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: 08/16/2023] [Accepted: 09/08/2023] [Indexed: 03/23/2024] Open
Abstract
Background Recent studies have reported conflicting results as to whether isolated medial patellofemoral ligament reconstruction (MPFLr) leads to decreased patellar height. Purpose To investigate if patellar stabilization surgery not intended to address patella alta influences patellar height. Study Design Cohort study; Level of evidence, 3. Methods A multicenter retrospective chart review was conducted, and patients who underwent MPFLr, medializing tibial tuberosity osteotomy (TTO), and/or trochleoplasty between 2016 and 2020 were included. The Caton-Deschamps index (CDI) was calculated from radiographs obtained preoperatively, 2 weeks postoperatively, and 3 months postoperatively. The preoperative CDI value was compared with the 2-week postoperative and 3-month postoperative values according to stabilization procedure (isolated MPFLr, isolated TTO, MPFLr + TTO, MPFLr + trochleoplasty, and MPFLr + trochleoplasty + TTO) using the paired t test. Analyses of the 1-bundle versus 2-bundle MPFLr technique and the presence of lateral retinacular release or lateral retinacular lengthening were conducted on the isolated MPFLr and combined MPFLr + TTO cohorts. Results A total of 356 knees were included. Statistically significant pre- to postoperative decreases in CDI were seen in all stabilization procedures analyzed (P≤ .017 for all). Within the isolated MPFLr cohort, this significant decrease was seen at 2 weeks postoperatively with the 2-bundle technique (ΔCDI = -0.09; P < .001) but not with the 1-bundle technique (ΔCDI = -0.01; P = .621). Conclusion The different surgical techniques analyzed in the current study affected patellar height, even when a distalizing TTO was not performed. The decrease was dependent on surgical technique, with a 2-bundle MPFLr leading to a statistically significant decrease and a 1-bundle MPFLr effecting no change.
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Affiliation(s)
- R. Timothy Kreulen
- Department of Orthopaedic Surgery, Johns Hopkins, School of Medicine, Baltimore, Maryland, USA
| | - Gregory Anderson
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sercan Yalcin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph M. Hart
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kaitlyn Shank
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew S. Fury
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John J. Elias
- Department of Health Sciences, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lutul D. Farrow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - David R. Diduch
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins, School of Medicine, Baltimore, Maryland, USA
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Yilmaz ET, Goymen IM, Oral M, Tuncay O, Dursun G, Turhan E, Tokgozoglu AM. Translation, reliability and validity of the Turkish versions of Norwich Patellar Instability score and The Banff Patellar Instability Instrument 2.0. J Orthop Surg Res 2024; 19:140. [PMID: 38355539 PMCID: PMC10865514 DOI: 10.1186/s13018-024-04612-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Current treatment options for patellofemoral (PF) instability have required functional scoring systems. The Banff Patellar Instability Instrument (BPII) 2.0 and Norwich Patellar Instability (NPI) scores were explicitly created to meet the need to evaluate PF instability. Different patient-reported outcome measurements (PROMs) are used to evaluate anterior knee problems. OBJECTIVES To test the validity and reliability of the Turkish version of the BPII 2.0 and NPI score. STUDY DESIGN AND METHODS Fifty-one patients that operated for PF instability, older than eighteen years old, were included in this study. Turkish translation of the BPII 2.0 and NPI scores was undertaken through translation into Turkish by an independent translator. Two tests were repeated seven days apart. Intraclass correlation coefficient (ICC) was used for test-retest reliability. Internal consistency was analyzed using Cronbach's alpha. Validity was assessed by correlating the Kujala and Lysholm knee scores. RESULTS Fifty-one patients (34 females/17 males), the average age was 25 ± 7, were included in this study. Cronbach's alpha value was 0.829 for BPII 2.0 and 0.843 for NPI for the first time answered by patients. ICC values applied to evaluate test-retest reliability were 0.904 (p < 0.05) for BPII 2.0 and 0.915 (p < 0.05) for NPI. There was a moderate correlation between the BPII 2.0 Turkish version and the Kujala score. There was a very high correlation between the Turkish version of the BPII 2.0 and Lysholm knee scores. An excellent negative correlation was found between Norwich and Kujala scores (r = -0.819, p < 0.05). The correlation coefficient between Norwich and Lysholm scores was -0.662, indicating a high negative correlation (p < 0.05). The correlation coefficients between the Turkish version of BPII 2.0 and NPI were -0.533 (p < 0.05). CONCLUSIONS The Turkish version of the BPII 2.0 and NPI score is a reliable and valid instrument for Turkish-speaking patients with patellofemoral instability.
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Affiliation(s)
- Engin Turkay Yilmaz
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
| | - Ibrahim Mehmet Goymen
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey.
| | - Melih Oral
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
| | - Ozan Tuncay
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
| | - Gokay Dursun
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
| | - Egemen Turhan
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
| | - Ahmet Mazhar Tokgozoglu
- Orthopedics and Traumatology Department, Hacettepe University Medical School, Ankara, Turkey
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Zhang Y, Nan K, Zhao Y, Zhang X, Song Q, Fan L, Shi Z, Dang X. Addition of Tibial Tubercle Osteotomy to Combined MPFL Reconstruction and Lateral Retinacular Release not Recommended for Recurrent Patellar Dislocation in Patients with 15 to 20 mm TT-TG. J Knee Surg 2023; 36:1349-1356. [PMID: 36564044 DOI: 10.1055/s-0042-1757593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Surgery is the primary treatment for recurrent patellar dislocation. However, there is still a lack of consensus regarding the choice of combined surgical methods due to the complexity of the anatomical factors. This study aimed to investigate the efficacy and radiological changes in medial patellofemoral ligament reconstruction (MPFLR) and lateral retinacular release (LRR) with and without tibial tubercle osteotomy (TTO) for recurrent patellar dislocation in patients with a tibial tubercle-trochlear groove (TT-TG) distance of 15 to 20 mm. Fifty-four patients were enrolled in this retrospective study between 2010 and 2014. The average patient age was 21.6 ± 5.0 years. All patients underwent MPFLR and LRR, and in 18 patients, these procedures were combined with TTO. Patients were evaluated preoperatively and postoperatively for patellar lateral shift, patellar tilt angle, TT-TG distance, Q-angle, Caton-Deschamps index (CDI), Kujala, and Lysholm scores. The minimally clinical important difference was used to compare clinical outcomes between two groups. In the mean follow-up of 82.6 ± 15.9 months, functional scores improved significantly in both groups (p < 0.01). There were no significant differences in postoperative function scores between the two groups (Kujala, p = 0.25, mean difference = 1.5, 95% confidence interval [CI]: -1.4-4.4; Lysholm, p = 0.76, mean difference = -0.6, 95% CI: -5.9-4.7). Additionally, TTO significantly decreased Q-angle (23.6 ± 2.4 vs. 17.4 ± 2.9, p < 0.01), TT-TG (17.1 ± 1.5 vs. 10.4 ± 1.8, p < 0.01), and CDI (1.18 ± 0.12 vs. 1.08 ± 0.07, p < 0.01). Combined MPFLR and LRR with and without TTO are both effective techniques for recurrent patellar dislocation. Additional osteotomy can correct patellar alta and tibial tubercle lateralization. However, given that there were no significant differences in postoperative functional scores or recurrence rate between groups, we may not recommend TTO in addition to MPFLR and LRR in patients with TT-TG of 15 to 20 mm. Long-term and prospective cohort studies are required to assess further outcomes.
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Affiliation(s)
- Yuankai Zhang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Kai Nan
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
- Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Yan Zhao
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Xin Zhang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Qichun Song
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Lihong Fan
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Zhibin Shi
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Xiaoqian Dang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
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Berk AN, Gachigi KK, Trofa DP, Piasecki DP, Fleischli JE, Saltzman BM. Early Postoperative Complications and Associated Variables After Tibial Tubercle Osteotomy: A 15-Year Experience From a Single Academic Institution. Orthop J Sports Med 2023; 11:23259671231194367. [PMID: 37868217 PMCID: PMC10585996 DOI: 10.1177/23259671231194367] [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: 03/31/2023] [Accepted: 05/05/2023] [Indexed: 10/24/2023] Open
Abstract
Background Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patients with patellofemoral disorders. Purpose To determine the rate of early (≤90 day) postoperative complications after TTO and variables related to postoperative complications. Study Design Case series; Level of evidence, 4. Methods Patients who underwent TTO at a single academic institution within a 15-year period (2008-2022) were identified. All patients with a minimum 90-day follow-up were considered for study inclusion. Exclusion criteria were age younger than 14 years and revision surgery. Patient characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. Results A total of 344 knees in 313 patients met eligibility criteria and were included in the final analysis. One intraoperative complication (0.3%), a premature closure of the incision before repair of the vastus medialis, was identified. There were 141 postoperative complications (138 surgical, 3 medical) in 118 patients for a complication rate of 34.3%. The most common complications were stiffness requiring a nonstandard-of-care intervention (16.3%), superficial wound infection/wound dehiscence (8.1%), and hemarthrosis/effusion requiring aspiration (5.8%). Patients experiencing postoperative complications were older (mean difference, 3.49 years; 95% CI, 1.26-5.73 years; P = .002), had a higher mean Charlson Comorbidity Index (mean difference, 0.26; 95% CI, 0.08-0.45; P = .006), and were more likely to be current smokers (P = .015) compared with patients with no complications. Inpatient surgery (defined as surgery in a hospital setting with at least 1 overnight stay) was associated with postoperative complications (odds ratio [OR], 2.29; 95% CI, 1.39-3.77; P = .001); this association remained significant generation of a multivariate model (OR, 2.07; 95% CI, 1.19-3.58; P = .010). Previous surgery on the ipsilateral knee (P < .001) and concomitant autologous chondrocyte implantation (P = .046) were also associated with postoperative complications. Conclusion The study findings indicated a low intraoperative complication rate (0.3%) and a relatively high early postoperative (≤90 day) complication rate (34.3%) after TTO. Variables associated with postoperative complications included greater age, higher Charlson Comorbidity Index, surgery in an inpatient setting, previous surgery on the ipsilateral knee, and concomitant autologous chondrocyte implantation.
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Affiliation(s)
- Alexander N. Berk
- OrthoCarolina-Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health-Musculoskeletal Institute, 1320 Scott Ave, Charlotte, North Carolina, USA
| | - Kennedy K. Gachigi
- OrthoCarolina-Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
| | - David P. Trofa
- Department of Orthopaedics, New York Presbyterian, Columbia University Medical Center, New York, New York, USA
| | - Dana P. Piasecki
- OrthoCarolina-Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health-Musculoskeletal Institute, 1320 Scott Ave, Charlotte, North Carolina, USA
| | - James E. Fleischli
- OrthoCarolina-Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health-Musculoskeletal Institute, 1320 Scott Ave, Charlotte, North Carolina, USA
| | - Bryan M. Saltzman
- OrthoCarolina-Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health-Musculoskeletal Institute, 1320 Scott Ave, Charlotte, North Carolina, USA
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Samelis PV, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus 2023; 15:e46743. [PMID: 38021800 PMCID: PMC10631568 DOI: 10.7759/cureus.46743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
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Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis and Aglaia Kyriakou, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Panagiotis Koulouvaris
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Olga Savvidou
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Andreas Mavrogenis
- Orthopaedics, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Panayiotis J Papagelopoulos
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
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Ratano S, Ponzio EM, Camarda L. Tibial tubercle osteotomy: effect of different osteotomy planes on contact surface area and tubercle anteriorization. Musculoskelet Surg 2023; 107:361-366. [PMID: 36580268 DOI: 10.1007/s12306-022-00770-x] [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: 09/23/2020] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
In 1983, Fulkerson introduced a technique of tibial tubercle osteotomy performed according to an inclined plane with respect to frontal plane. Due to obliquity of the osteotomy plane, this procedure allows both anterior and medial transfer of the tibial tubercle. The purpose of the study was to investigate the influence of the different degrees of the oblique plane of osteotomy on anterior displacement and the contact surface area of tibial tubercle. Synthetic bones were used for the study. An osteotomy of the tibial tubercle (TT) was performed in each specimen. Specifically, 3 different degrees of osteotomy planes relative to the reference frontal plane were examined: 20°, 30° and 40°. On each sample, tibial tubercle medial transposition of 5 mm, 10 mm and 15 mm was performed. Anterior displacement was measured with a caliper. Further, the bone contact surface was calculated for each sample and each transposition. Finally, the measured data were statistically compared with a geometric model. At 5 mm of medial TT transposition, the anterior displacement (AD) was 0.1 mm when the osteotomy was performed at 20°. It increased of 1.5 mm and 2.7 mm, respectively at 30° and 40°. At 15 mm of TT transposition, the AD was 3.4 mm at 20°, 7.6 mm at 30° and 10.0 mm at 40°. Concerning the amount of medialization, it was observed a decrease in the overall contact surface passing from 5 to 15 mm of TT transposition. In addition, regarding the oblique plane of the osteotomy, it was observed an increase in the contact surface area passing from 20° to 40°. The main result of the present study is that the amount of anteriorization and medialization of the tibial tubercle could be predicted by the degrees of oblique plane of osteotomy. An increase in medialization significantly reduces the contact surface area at low degrees of osteotomy plane, potentially increasing the risk of non-union.
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Affiliation(s)
- Salvatore Ratano
- Department of Orthopaedics and Traumatology (DICHIRONS), University of Palermo, Palermo, Italy
- Department of Orthopaedic Surgery (DICHIRINOS), University of Palermo, Via del Vespro, 127, 90100, Palermo, Italy
| | - Elena Maria Ponzio
- Department of Orthopaedics and Traumatology (DICHIRONS), University of Palermo, Palermo, Italy
- Department of Orthopaedic Surgery (DICHIRINOS), University of Palermo, Via del Vespro, 127, 90100, Palermo, Italy
| | - Lawrence Camarda
- Department of Orthopaedics and Traumatology (DICHIRONS), University of Palermo, Palermo, Italy.
- Department of Orthopaedic Surgery (DICHIRINOS), University of Palermo, Via del Vespro, 127, 90100, Palermo, Italy.
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11
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Gebhardt S, Zimmerer A, Zimmermann F, Wassilew GI, Balcarek P. Revision lateralization osteotomy of the tibial tubercle has excellent outcomes in patients suffering from previous medial tibial tubercle overcorrection. Arch Orthop Trauma Surg 2023; 143:4323-4329. [PMID: 36418610 PMCID: PMC10293333 DOI: 10.1007/s00402-022-04700-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Tibial tubercle osteotomy (TTO) is a common procedure used to treat patients with patellofemoral instability (PFI) and osteoarthritis (PFOA). Medial patellar maltracking due to previous excessive medialization of the tibial tubercle has rarely been reported. Therefore, the goal of this study was to assess patient-reported outcome measures (PROMs) after revision osteotomy with lateralization of the tibial tubercle (RL-TTO) to correct medial patellofemoral maltracking. MATERIALS AND METHODS Between 2017 and 2021, a series of 11 patients (male/female 1/10; age 35.8 ± 10.5 years) were treated by RL-TTO, of whom 8 patients could be retrospectively evaluated after a mean of 32.4 ± 15.1 months (range 18-61 months) postoperatively. The Kujala anterior knee pain scale, the patellofemoral subscale of the Knee Osteoarthritis and Outcome Score (KOOS-PF), and a numeric analog scale (NAS; 0-10) regarding anterior knee pain (AKP) at rest and during activity were assessed from pre- to postoperatively. RESULTS The preoperative mean tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances were - 6.5 ± 6.5 mm and 0.7 ± 4.6 mm, respectively. The intraoperatively determined amount of tibial tubercle lateralization averaged 10.7 ± 3.6 mm. The Kujala score and KOOS-PF improved significantly from 33.6 ± 10.1 (23-51) points to 94.4 ± 6.2 points (82-100) (p < 0.001) and from 20.6 ± 13.2 points (0-43.3) to 87.3 ± 9.9 points (72.8-100) (p < 0.001) from pre- to postoperatively, respectively. Pain at rest decreased from 5.8 ± 1.9 to 0.8 ± 0.9 (p < 0.001), and pain during activity decreased from 8.6 ± 1.3 to 1.6 ± 1.5 (p < 0.001). CONCLUSION RL-TTO significantly improved subjective knee function and AKP in patients suffering from medial patellar maltracking due to previous excessive tibial tubercle medialization osteotomy at short-term follow-up.
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Affiliation(s)
- Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Hansestadt Greifswald, Germany
| | - Alexander Zimmerer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Hansestadt Greifswald, Germany
- ARCUS Sportsclinic, Rastatterstr. 17-19, 75179 Pforzheim, Germany
| | - Felix Zimmermann
- BGU Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany
| | - Georgi I. Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Hansestadt Greifswald, Germany
| | - Peter Balcarek
- ARCUS Sportsclinic, Rastatterstr. 17-19, 75179 Pforzheim, Germany
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12
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Barroso Rosa S, Grant A, McEwen P. Patient-reported outcome measures for patellofemoral disorders: a systematic review. Arch Orthop Trauma Surg 2023; 143:3919-3927. [PMID: 36260119 DOI: 10.1007/s00402-022-04663-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Patellofemoral conditions include, but are not limited to, anterior knee pain syndrome and patellar instability. Patients and surgeons may find it difficult to identify the specific source of the symptoms and clinical scenarios, so patient-reported outcome measures (PROMs) may be a useful diagnostic aid. There are a number of available PROMs for patellofemoral conditions, which are often used indistinctly. This systematic review explores the available PROMs for patellofemoral conditions, their use and methodological quality. METHODS A systematic review was conducted, searching for scientific articles relating to PROMs in patellofemoral conditions, from inception to July 2022. Scoring systems including physician-directed or imagining assessment were not included. All types of conditions in the patellofemoral joint were considered. RESULTS Twenty-two relevant PROMs were encountered, divided into four categories: eight PROMs for anterior knee pain syndrome, five for patellar instability, four for other patellofemoral conditions and five for non-specific PROMs. CONCLUSIONS While many PROMs have been found used in patellofemoral research, only few of them have showed sufficient methodological quality. In addition, PROMs employed in PF literature are often inaccurately chosen. This review may help authors to better understand the characteristics of specific patellofemoral PROMs, in order to select the more appropriate and recommended ones. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sergio Barroso Rosa
- Departamento de Ciencias Médicas y Quirúrgicas, Universidad de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain.
- The Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.
| | - Andrea Grant
- The Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
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13
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Yalcin S, Seals K, McLaughlin W, Fulkerson JP, Farrow LD. Incidence of Early Adverse Events After Tibial Tubercle Osteotomy. Orthop J Sports Med 2023; 11:23259671231178345. [PMID: 37441509 PMCID: PMC10334009 DOI: 10.1177/23259671231178345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/09/2023] [Indexed: 07/15/2023] Open
Abstract
Background Tibial tubercle osteotomy (TTO) is a commonly utilized surgical procedure for the treatment of patellofemoral instability. Although midterm and long-term outcomes are known, perioperative complications have not been consistently reported. Purpose To identify the incidence and predictors of adverse events in the first 90-day perioperative period after TTO. Study Design Case series; Level of evidence, 4. Methods Patients undergoing primary TTO between January 1, 2010, and December 31, 2019, were included. Readmissions in the first 90 days after surgery were collected, and data were collected for the following variables: age, sex, smoking status, body mass index, laterality, preoperative diagnosis, presence of trochlear dysplasia, tourniquet use, TTO procedure, tibial tubercle distalization, trochleoplasty, chondral procedure, number of screws, and use of an epidural catheter. Predictors of readmission for any reason were identified using multivariable logistic regression analysis. Results A total of 345 TTO procedures were included in the final analysis. The incidence of readmissions for any reason was 20.6% (71/345). The most common reason for readmission was postoperative pain (26/345 [7.5%]), followed by wound complications (19/345 [5.5%]) and epidural catheter-related complications (overall: 16/345 [4.6%]; specific: 16/167 [9.6%]. The incidence of major complications was 2.0% (7/345). The number of patients with each major complication was as follows: 1 for deep vein thrombosis, 2 for pulmonary embolism, 1 for septic arthritis, 1 for tibial tubercle fracture, and 2 for loss of fixation. Female sex and smoking were associated with readmission for pain. Conclusion The incidence of major complications after TTO was very low (2.0%), but 20.6% of cases required readmission, primarily for an indwelling epidural catheter (3.5%) and postoperative pain (7.5%). Concomitant soft tissue procedures and the number of screws were associated with readmission after TTO. Utilizing individualized postoperative pain management and preoperative discussions about expected pain may help to avoid readmission for pain after TTO.
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Affiliation(s)
- Sercan Yalcin
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Karrington Seals
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - William McLaughlin
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - John P Fulkerson
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lutul D Farrow
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Dewan V, Gudipati S, Rooney J, Lloyd A, Chugh S, Mughal E. Medial patellofemoral ligament reconstruction and tibial tuberosity transfer can be used to successfully manage patellofemoral instability in the setting of trochlea dysplasia. Knee Surg Relat Res 2023; 35:11. [PMID: 37106401 PMCID: PMC10141911 DOI: 10.1186/s43019-023-00181-7] [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: 06/05/2022] [Accepted: 02/28/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Management of patella instability remains a challenge particularly in the presence of trochlea dysplasia. The aim of this study is to assess the recurrence rates of those with patellar instability who have undergone a combined tibial tuberosity transfer (TTT) and medial patellofemoral ligament reconstruction (MPFLR) in the setting of trochlea dysplasia. METHODS All skeletally mature patients who underwent combined TTT and MPFLR for recurrent patella instability were identified between January 2009 and December 2019. A retrospective review was conducted, with information regarding re-dislocation/subluxation and complications collected. RESULTS Seventy patients with a mean age 25.3 years were identified and evaluated. Thirteen patients were found to have low-grade dysplasia (Dejour A), with 57 patients having high-grade dysplasia (Dejour B/C/D). No patients in the low,grade dysplasia group suffered a recurrence of their symptoms, with four in the high-grade group suffering episodes of re-dislocation/subluxation. Three patients subsequently underwent a trochleoplasty, with the other patient managed successfully non-operatively. There were a total of 13 complications in 11 patients. CONCLUSIONS A combined procedure of MPFLR and TTT can be used to manage patellofemoral instability even in the setting of trochlea dysplasia with a low rate of recurrence. Trochlea dysplasia, however, remains an anatomical risk factor for recurrence and patients should be counselled accordingly. The anatomical risk factors should be assessed in all patients to allow for the development of the most appropriate management plan, of which this combined procedure represents a potentially successful option. LEVEL OF EVIDENCE IV (Case Series).
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Affiliation(s)
- Varun Dewan
- New Cross Hospital, Wolverhampton Road, Heath Town, Wolverhampton, WV10 0QP, UK.
| | - Suribabu Gudipati
- New Cross Hospital, Wolverhampton Road, Heath Town, Wolverhampton, WV10 0QP, UK
| | - Joanna Rooney
- Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, SK2 7JE, UK
| | - Adam Lloyd
- New Cross Hospital, Wolverhampton Road, Heath Town, Wolverhampton, WV10 0QP, UK
| | - Sanjiv Chugh
- New Cross Hospital, Wolverhampton Road, Heath Town, Wolverhampton, WV10 0QP, UK
| | - Ejaz Mughal
- New Cross Hospital, Wolverhampton Road, Heath Town, Wolverhampton, WV10 0QP, UK
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15
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Drapeau-Zgoralski V, Swift B, Caines A, Kerrigan A, Carsen S, Pickell M. Lateral Patellar Instability. J Bone Joint Surg Am 2023; 105:397-409. [PMID: 36728086 DOI: 10.2106/jbjs.22.00756] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
➤ Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology. Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient. ➤ Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity. ➤ Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment. ➤ Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability. ➤ Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation. ➤ Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta. ➤ The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding. ➤ Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30° to improve patient outcomes and reduce recurrence rates.
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Affiliation(s)
| | - Brendan Swift
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew Caines
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alicia Kerrigan
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Michael Pickell
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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16
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Lamplot JD, Jahandar A, Meyers KN, Gomoll AH, Maher SA, Strickland SM. Anteromedialization Tibial Tubercle Osteotomy Improves Patellar Contact Forces: A Cadaveric Model of Patellofemoral Dysplasia. Am J Sports Med 2023; 51:453-460. [PMID: 36453729 DOI: 10.1177/03635465221138287] [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] [Indexed: 12/02/2022]
Abstract
BACKGROUND Patellofemoral (PF) dysplasia is common in patients with recurrent patellar instability. Tibial tubercle osteotomy (TTO) is performed with goals of correcting patellar maltracking and redistributing contact forces across the PF joint. The biomechanical effects of TTO in the setting of PF dysplasia have not been quantified. PURPOSE/HYPOTHESIS To quantify patellar contact mechanics and kinematics after TTO in the setting of PF dysplasia. We hypothesized that a simulated anteromedialization (AMZ) TTO would improve PF contact mechanics as compared with a pure medialization TTO. STUDY DESIGN Controlled laboratory study. METHODS PF dysplasia with Dejour type D classification was simulated in 7 cadaveric knees by replacing the native patellar and trochlear surfaces with synthetic polymeric patellar and trochlear implants. On each specimen, a flat TTO was fixed in 3 distinct positions simulating a pathologic lateralized tubercle (pathologic condition), a medialized tubercle (Elmslie Trillat), and an AMZ tubercle. The sum of forces acting on the medial and lateral patellar facet and patellar kinematics was computed for each knee for each condition from 0° to 70° of flexion at 10° increments. RESULTS Relative to the pathologic condition, AMZ TTO decreased contact forces across the lateral facet (20°-50° and 70° of flexion). Relative to the pathologic condition, Elmslie Trillat TTO had no effect on contact forces on either compartment. Relative to the Elmslie Trillat TTO, the AMZ TTO had significantly decreased contact forces across the medial facet (at 40°, 60°, and 70° of flexion). No significant differences in joint kinematics occurred across any groups. CONCLUSION Of all groups studied, AMZ TTO resulted in significantly decreased patellar contact forces in simulated dysplastic PF joints. AMZ may be considered in certain patients with PF dysplasia to avoid medial compartment PF chondral overload. CLINICAL RELEVANCE PF dysplasia is common in patients with recurrent patellar instability who warrant surgical intervention to prevent subsequent recurrence. Numerous interventions to treat this condition, including various TTOs, have been proposed without a clear consensus. This cadaveric biomechanical study demonstrates that AMZ TTO resulted in more favorable PF contact mechanics than Elmslie Trillat TTO in a model representing PF dysplasia. AMZ TTO may be considered for patients in the setting of recurrent instability with PF dysplasia to avoid cartilage overload on the medial compartment of the PF joint.
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17
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Perry AK, Maheshwer B, DeFroda SF, Hevesi M, Gursoy S, Chahla J, Yanke A. Patellar Instability. JBJS Rev 2022; 10:01874474-202211000-00008. [PMID: 36441831 DOI: 10.2106/jbjs.rvw.22.00054] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
➢ Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢ The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢ Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢ More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.
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Affiliation(s)
- Allison K Perry
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | | | - Steven F DeFroda
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Mario Hevesi
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Adam Yanke
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
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18
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Kaplan DJ, Mojica ES, Ortega PF, Triana J, Strauss EJ, Jazrawi LM, Gonzalez-Lomas G. Posterior tibial tubercle measured by the sagittal TT-TG distance correlates with increased risk for patellofemoral chondral lesions. Knee Surg Sports Traumatol Arthrosc 2022; 30:3733-3741. [PMID: 35513456 DOI: 10.1007/s00167-022-06988-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01 ± 8.7, 26.6 ± 6.4, and 173.0 ± 17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (- 2.5 mm ± 5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72 mm ± 6.7) (p < 0.001). Interrater reliability was excellent (ICC = 0.931, p < 0.001). Patients with less than - 3.4 mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater than - 3.4 mm (OR 2.7, 95% CI 1.3-5.85). Patients with < - 10 mm posterior translation were 13.7× (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel J Kaplan
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA.
| | - Edward S Mojica
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Paola F Ortega
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Jairo Triana
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Eric J Strauss
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Laith M Jazrawi
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Guillem Gonzalez-Lomas
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
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19
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Vivekanantha P, Kahlon H, Cohen D, de Sa D. Isolated medial patellofemoral ligament reconstruction results in similar postoperative outcomes as medial patellofemoral ligament reconstruction and tibial-tubercle osteotomy: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 31:2433-2445. [PMID: 36214831 DOI: 10.1007/s00167-022-07186-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine the effect of isolated medial patellofemoral ligament reconstruction (MPFLR) versus concomitant MPFLR and tibial-tubercle osteotomy (TTO) on patient-reported functional outcomes, rate of patellar redislocation, and rate of return to sport in skeletally mature patients with recurrent patellar instability and lateralization as defined by elevated tibial-tubercle trochlear groove (TT-TG) distance. METHODS Three databases MEDLINE, PubMed and EMBASE were searched from inception to July 10th, 2022 for literature outlining the management of patients with TT-TG indices greater than 15 mm with either isolated MPFLR or concomitant MPFLR and TTO procedures. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on functional outcomes via the Kujala anterior knee pain score, redislocation rates, return to sport rates, and complications were recorded. The MINORS score was used for all studies to perform a quality assessment of included studies. RESULTS A total of 31 studies comprising 1405 patients (1452 knees) were included in this review. The mean Kujala score in 13 studies comprising 848 total patients in the isolated MPFLR group was 85.0 (range 80.9-97.5) compared to a score of 83.7 (range 77.2-94.0) in 14 studies comprising 459 patients in the concomitant group. The mean pooled redislocation rate in 19 studies examining isolated MPFLR procedures comprising 948 patients was 3.1% (95% CI 2.1-4.4%, I2 = 7%) as opposed to 3.2% (95% CI 1.9-5.0%, I2 = 0%) in 15 studies comprising 486 patients in the concomitant group. The mean pooled return to sport rate in seven studies with 472 total patients in the isolated MPFLR group was 82% (95% CI 78-86%, I2 = 16%) compared to a score of 92% (95% CI 78-99%, I2 = 58%) in four studies comprising 54 patients in the concomitant group. There were similar complication rates between both treatment groups, including range of motion deficits, fractures, infections, and graft failures. CONCLUSION Isolated MPFLR leads to similar anterior knee pain, similar redislocation rates and lower return to sport rates than concomitant MPFLR and TTO procedures in patients with TT-TG distances greater than 15 mm. Information from this review can aid surgeons in their decision to choose MPFLR versus concomitant procedures for this patient population, and can also guide future studies on this topic. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Harjind Kahlon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada.
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20
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Otsuki S, Ikeda K, Okuno N, Okamoto Y, Wakama H, Okayoshi T, Matsuyama J, Neo M. Three-dimensional transfer of tibial tuberosity for patellar instability with patella alta preserves patellar position and clinical outcomes: A minimum 3-year follow-up study. J Orthop Sci 2022; 27:1100-1106. [PMID: 34244026 DOI: 10.1016/j.jos.2021.06.003] [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: 09/04/2020] [Revised: 05/25/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The three-dimensional (3D) transfer of tibial tuberosity has been reported to improve patellofemoral congruity and showed good clinical outcomes during the short follow-up, however, little is known about whether the patellar position and clinical outcomes are preserved at longer follow-ups and the risk factors for poor clinical outcomes. HYPOTHESIS We hypothesized that patellar position and clinical outcomes would be preserved and the predisposing factors were associated with poor clinical outcomes after the 3D transfer of tibial tuberosity. PATIENTS AND METHODS Thirty-nine patients, with a mean age of 27.9 (15-52) years, who underwent the 3D transfer of the tibial tuberosity were enrolled. Patellar position was evaluated using the Caton-Deschamps index and patellar tilt. Clinical outcomes were evaluated with Lysholm and Kujala scores pre- and postoperatively. Age, body mass index (BMI), radiographic measurements, and range of motion (ROM) were compared between the poor group (defined as <80 points on Kujala score) and the good group (≥80 points). The mean follow-up period was 54.1 (36-100) months. RESULTS Patellar position decreased from 1.32 (1.21-1.53) preoperatively to 0.99 (0.84-1.07) at the final follow-up, according to the Caton-Deschamps index (p < 0.01). The mean patellar tilt decreased from 26.0° (21-40°) to 15.1° (5-28°) (p < 0.01). Kujala and Lysholm scales improved from 59.1 to 54.2 to 90.1 and 91.8 at final follow-up, respectively (p < 0.01). Increased BMI, lower femorotibial angle, limited ROM, and poor preoperative clinical outcomes were the predicting factors for poor postoperative clinical outcomes (p < 0.05). CONCLUSION The 3D transfer for patellar instability with patella alta preserved the patellar position and clinical outcomes for at least 3 years. Predisposing factors that may potentially affect postoperative clinical outcomes of the 3D transfer of tibial tuberosity include an increased BMI, valgus knee, limited ROM, and poor preoperative clinical outcomes.
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Affiliation(s)
- Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Nobuhiro Okuno
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Tomohiro Okayoshi
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Junya Matsuyama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Japan.
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21
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Guneri B, Kose O, Celik HK, Cakar A, Tasatan E, Rennie AEW. How to fix a tibial tubercle osteotomy with distalisation: A finite element analysis. Knee 2022; 37:132-142. [PMID: 35779431 DOI: 10.1016/j.knee.2022.06.002] [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: 01/04/2022] [Revised: 05/22/2022] [Accepted: 06/01/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Antero-medialisation osteotomy combined with a distalisation procedure may require a more stable fixation as the osteotomy fragment loses both proximal and distal support. This finite element analysis aimed to compare the mechanical behaviour of different fixation techniques in tibial tubercle antero-medialisation osteotomy combined with distalisation procedure. METHODS Tibial tubercle osteotomy combined with distalisation was modelled based on computerised tomography data, which were acquired from a patient with patellar instability requiring this procedure. Six different fixation configurations with two 3.5-mm cortical screws (1), two 4.5-mm cortical screws (2), three 3.5-mm cortical screws (3), three 4.5-mm cortical screws (4), three 3.5-mm screws with 1/3 tubular plate (5), and four 3.5-mm screws with 1/3 tubular plate (6) were created. A total of 1654 N of force was applied to the patellar tendon footprint on the tibial tubercle. Sliding, gap formation, and total deformation between the osteotomy components were analyzed. RESULTS Maximum sliding (0.660 mm), gap formation (0.661 mm), and displacement (1.267 mm) were seen with two 3.5-mm screw fixation, followed by two 4.5-mm screws, three 3.5-mm screws, and three 4.5-mm screws, respectively, in the screw-only group. Overall, the minimum displacement was observed with the four 3.5-mm screws with 1/3 tubular plate fixation model. CONCLUSIONS Plate fixation might be recommended for tibial tubercle antero-medialisation osteotomy combined with distalisation procedure because it might allow early active range of motion exercises and weight-bearing.
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Affiliation(s)
- Bulent Guneri
- Department of Orthopaedics and Traumatology, Adana City Education and Research Hospital, Adana, Turkey.
| | - Ozkan Kose
- Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - H Kursat Celik
- Department of Agricultural Machinery and Technology Engineering, Agricultural Faculty, Akdeniz University, Antalya, Turkey
| | - Albert Cakar
- Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Ersin Tasatan
- Department of Orthopaedics and Traumatology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
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22
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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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23
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Zheng ET, Kocher MS, Wilson BR, Hussain ZB, Nunally KD, Yen YM, Kramer DE, Micheli LJ, Heyworth BE. Descriptive Epidemiology of a Surgical Patellofemoral Instability Population of 492 Patients. Orthop J Sports Med 2022; 10:23259671221108174. [PMID: 35859643 PMCID: PMC9289910 DOI: 10.1177/23259671221108174] [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: 12/15/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patellofemoral instability (PFI) occurs most commonly in pediatric and
adolescent patients, with evolving indications for surgery and changes in
surgical techniques over the past decade. Purpose: To characterize the demographic, clinical, and radiologic characteristics of
a large cohort of patients undergoing PFI surgery and investigate
longitudinal trends in techniques utilized over a 10-year period at a
tertiary-care academic center. Study Design: Case series; Level of evidence, 4. Methods: Electronic medical records of patients younger than 25 years of age who
underwent primary surgery for lateral PFI from 2008 to 2017 at a single
center by 1 of 5 different sports medicine surgeons were retrospectively
reviewed. Demographic, clinical, and radiographic parameters of instability
were analyzed. Routine surgical techniques included medial retinacular
plication/reefing/repair (MRP), medial patellofemoral ligament
reconstruction (MPFLR), tibial tubercle osteotomy (TTO), or a combination
thereof, with or without lateral retinacular release (LR) or lateral
retinacular lengthening (LRL). Exclusion criteria, selected for potentially
altering routine surgical indications or techniques, included
fixed/syndromic PFI, a formally diagnosed collagen disorder, cases in which
a chondral/osteochondral shear fragment underwent fixation or was >1 cm
in diameter, and body mass index >30 kg/m2. Results: Of the 492 study patients (556 knees; 71% female; median age, 15.2 years; 38%
open physes), 88% were athletes, with the most common sports participated in
being soccer, basketball, dance, football, gymnastics, and
baseball/softball. While 91% of the cohort had recurrent dislocations, the
9% with primary dislocations were more likely to have small osteochondral
fractures/loose bodies (P < .001). Female patients were
younger (P = .002), with greater patellar tilt
(P = .005) than male patients. Utilization of MPFLR and
TTO increased significantly over the study period, while use of MRP+LR
decreased. Conclusion: Most patients younger than 25 years of age who underwent PFI surgery were
skeletally immature, female, and athletes and had recurrent dislocations.
The <10% who had primary dislocations and underwent surgery were likely
to have osteochondral fractures. Surgical techniques have changed
significantly over time, with increasing use of TTO and MPFLR, while the use
of MRP+LR/LRL has significantly decreased.
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Affiliation(s)
- Evan T Zheng
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin R Wilson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kianna D Nunally
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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24
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Keltz E, Ofir D, Beer Y, Gruber N, Falah M, Nierenberg G. Surgical Correction of Non-traumatic Patella Maltracking. Midterm Clinical Follow-up. Rambam Maimonides Med J 2022; 13:RMMJ.10465. [PMID: 35290178 PMCID: PMC9049154 DOI: 10.5041/rmmj.10465] [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] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patellar instability comprises a group of pathologies that allow the patella to move out of its trajectory within the trochlear groove during walking. Symptomatic patients who need surgery commonly undergo soft tissue procedures such as medial patellofemoral ligament repair to strengthen the ligaments that hold the patella in place. However, soft-tissue repairs may be insufficient in patients suffering from patellar maltracking, which is characterized by an unbalanced gliding of the patella within its route. In these patients, a different approach is advised. We aim to provide the mid-term clinical outcomes of the Fulkerson distal realignment operation in selected patients with non-traumatic patellar maltracking. METHODS The clinical outcomes of the Fulkerson distal realignment operation performed in 22 knees of 21 patients were evaluated by a self-administered subjective International Knee Documentation Committee (IKDC) score and the Tegner-Lysholm knee scoring scale. RESULTS Before surgery, the median IKDC score was 52, and the median Tegner-Lysholm score was 56. Following surgery (mean follow-up 48 months, range 24-156), the median IKDC and the Tegner-Lysholm scores were 67 and 88, respectively. The improvement was statistically significant (P=0.001 and P=0.002 for IKDC and Tegner-Lysholm scores, respectively). Associated procedures included patella microfracture due to grade III-IV cartilage lesion (International Cartilage Repair Society grading system) in four patients, retinacular releases in three patients, medial capsular augmentations in two patients, and medial patellofemoral ligament reconstruction in two patients. One patient with Ehlers-Danlos disease required excessive medialization of the tibial tuberosity. Surgery-related complications occurred in three patients. DISCUSSION Surgical correction of patellar maltracking with Fulkerson distal realignment combined with associated procedures in individual patients was associated with an increase in subjective and functional clinical scores at medium-term follow-up. Particular attention should address pathologies associated with patellar maltracking and managed accordingly. LEVEL OF EVIDENCE 4c (case series).
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Affiliation(s)
- Eran Keltz
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- To whom correspondence should be addressed. E-mail: or
| | - Dror Ofir
- Division of Orthopedic Surgery, Sourasky Medical Center, Tel Aviv, Israel
| | - Yiftah Beer
- Department of Orthopedic Surgery, Assaf Harofeh Medical Center, Zrifin, Israel
| | - Naama Gruber
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Mezen Falah
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Gabriel Nierenberg
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Sports Traumatology & Cartilage Regeneration Service, Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
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25
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Yang CP, Chang CH, Weng CJ, Hung KT, Chen ACY, Hsu KY, Chan YS. Older age and varus alignment lead to early failure in treating patellofemoral osteoarthritis with Fulkerson osteotomy. J Orthop Surg (Hong Kong) 2022; 29:23094990211061248. [PMID: 34875927 DOI: 10.1177/23094990211061248] [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] [Indexed: 11/16/2022] Open
Abstract
Background: It is unclear the risk factors for the failure of modified Fulkerson osteotomy. Methods: We retrospectively reviewed 40 patients who underwent the modified Fulkerson osteotomy from 1998 to 2015. There were 4 males and 36 females. The mean age of the study group was 50.2 ± 11.2 years. We used standard anteriorization measuring 10-15 mm and medialization measuring 10 mm while maintaining an intact periosteal sleeve. Results: Both the patellofemoral angle and the congruence angle improved significantly after 5.9 years. Preoperatively, the mean preoperative Lysholm score was 56.12, and the Knee Society score was 60.52. At the final follow-up, these scores improved significantly to 88.75 and 86.49, respectively. However, eight patients (20%) underwent total knee arthroplasty in the follow-up period, five of whom underwent the operation within 5 years. Comparing the survival and non-survival groups, there was a significant difference of an older age in the TKA conversion group (survival: 48.3 ± 11.1; non-survival: 57.8 ± 8.7, p = 0.03). For knee alignment, the non-survival group had a mean valgus femorotibial angle of 1.8° ± 4.9° preoperatively, and the survival group had a mean valgus angle of 6.4° ± 4.5° (p = 0.03). Conclusions: we found that patients with older age and those with varus alignment have an increased risk of deteriorated medial femorotibial cartilage.
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Affiliation(s)
- Cheng-Pang Yang
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyaun, Taiwan
| | - Chun-Hao Chang
- Graduate Institute of Sports Science, 63369National Taiwan Sport University, Taoyuan, Taiwan
| | - Chun-Jui Weng
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyaun, Taiwan
| | - Kung-Tseng Hung
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Alvin Chao-Yu Chen
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyaun, Taiwan
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyaun, Taiwan
| | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Division of Sports Medicine 38014Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou Taoyuan, Taiwan, Republic of China.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyaun, Taiwan
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26
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Zhou MAJL, Cruz CPTCA, Johnson MAJZA, Bottoni CR. Outcomes of Patellar Stabilization Utilizing a Combined Arthroscopic and Open Technique: A Retrospective Review With 5-Year Follow-up. Orthop J Sports Med 2022; 10:23259671211068404. [PMID: 35237696 PMCID: PMC8883305 DOI: 10.1177/23259671211068404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Few studies have reported the long-term outcomes of patellar stabilization surgery in an active duty military cohort. Purpose: To evaluate the long-term results of a combined open and arthroscopic patellar stabilization technique for the treatment of recurrent lateral patellar instability in members of a military population. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective review of a consecutive series of 63 patients who underwent operative management for patellar instability at a tertiary military medical center between 2003 and 2017. All cases were performed by a single sports medicine fellowship–trained orthopaedic surgeon. Patients with recurrent lateral patellar instability whose nonoperative management failed were included. All patients underwent arthroscopic imbrication of the medial patellar retinaculum, an open lateral retinacular release, and an Elmslie-Trillat tibial tubercle osteotomy. Outcome measures at final follow-up included recurrent instability, need for surgical revision, subjective assessments, and military-specific metrics. We also analyzed anatomic risk factors for failure: patella alta, coronal plane alignment, trochlear dysplasia, and tibial tubercle–trochlear groove distance. Results: A total of 51 patients were included (34 men, 17 women; mean ± SD age at surgery, 27.2 ± 5.8 years; mean follow-up, 5.3 years). The mean postoperative SANE score (Single Assessment Numeric Evaluation) was 75.0 ± 17.7, and the mean visual analog scale pain score was 2.5 ± 2.1. Four patients (7.8%) reported redislocation events, and 4 underwent revision surgery. Twenty-five patients (49.0%) reported a decrease in activity level as compared with preinjury, while 10 (19.6%) cited restrictions in activities of daily living. Of the 21 patients remaining on active duty, 6 (28.6%) required an activity-limiting medical profile. Of the 48 active duty patients, 12 (25.0%) underwent evaluation by a medical board for separation from the military. Differences in the Caton-Deschamps Index and tibial tubercle–trochlear groove distance between surgical success and failure were not statistically significant. Conclusion: Surgical management of patellar instability utilizing a multifaceted technique resulted in low recurrence rates and may be independent of predisposing anatomic risk factors for instability. At 5-year follow-up, most patients retained their active duty status, although nearly half experienced a decrease in activity level.
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Affiliation(s)
- MAJ Liang Zhou
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - CPT Christian A. Cruz
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | | | - Craig R. Bottoni
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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27
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Influence of Articular Geometry and Tibial Tubercle Location on Patellofemoral Kinematics and Contact Mechanics. J Appl Biomech 2022; 38:58-66. [PMID: 35045394 DOI: 10.1123/jab.2021-0162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/03/2021] [Accepted: 12/08/2021] [Indexed: 11/18/2022]
Abstract
Trochlear groove geometry and the location of the tibial tubercle, where the patellar tendon inserts, have both been associated with patellofemoral instability and can be modified surgically. Although their effects on patellofemoral biomechanics have been investigated individually, the interaction between the two is unclear. The authors' aim was to use statistical shape modeling and musculoskeletal simulation to examine the effect of patellofemoral geometry on the relationship between tibial tubercle location and patellofemoral function. A statistical shape model was used to generate new knee geometries with trochlear grooves ranging from shallow to deep. A Monte Carlo approach was used to create 750 knee models by randomly selecting a geometry and randomly translating the tibial tubercle medially/laterally and anteriorly. Each knee model was incorporated into a musculoskeletal model, and an overground walking trial was simulated. Knees with shallow trochlear geometry were more sensitive to tubercle medialization with greater changes in lateral patella position (-3.0 mm/cm medialization shallow vs -0.6 mm/cm deep) and cartilage contact pressure (-0.51 MPa/cm medialization shallow vs 0.04 MPa/cm deep). However, knees with deep trochlear geometry experienced greater increases in medial cartilage contact pressure with medialization. This modeling framework has the potential to aid in surgical decision making.
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28
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Agarwalla A, Liu JN, Wu HH, Kalbian IL, Garcia GH, Shubin Stein BE. Return to Work Following Tibial Tubercle Osteotomy for Patellofemoral Osteoarthritis and Pain. Cartilage 2021; 13:1066S-1073S. [PMID: 32321284 PMCID: PMC8808776 DOI: 10.1177/1947603520916544] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To evaluate the ability of patients to return to work following anteromedialization (AMZ) tibial tubercle osteotomy (TTO) due to isolated patellofemoral osteoarthritis or pain. METHODS Consecutive patients undergoing AMZ TTO were reviewed retrospectively at a minimum of 1 year postoperatively. Patients completed a subjective work questionnaire, a visual analog scale for pain, as well as a Kujala questionnaire and satisfaction questionnaire. RESULTS Fifty-seven patients (61 knees; average age: 32.7 ± 9.6 years) were contacted at an average follow-up of 4.86 ± 2.84 years postoperatively. The preoperative Kujala score improved from 55.7 ± 17.8 to 84.6 ± 15.8 at final follow-up (P < 0.001). Thirty-seven patients (64.9%) were employed within 3 years prior to surgery and 34 patients (91.9%) were able to return to work by 2.8 ± 2.6 months postoperatively. However, only 27 patients (73.0%) of patients were able to return to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations were able to return to work at a rate of 100.0%, 93.8%, 77.8%, and 100.0% by 2.2 months, 3.0 months, 3.1 months, and 4.0 months, postoperatively. No patients underwent revision TTO or conversion to arthroplasty by the time of final follow-up. CONCLUSION In patients with focal patellofemoral osteoarthritis or pain, AMZ TTO provides a high rate of return to work (91.9%) by 2.8 ± 2.6 months postoperatively. Patients with higher intensity occupations may take longer to return to work than those with less physically demanding occupations. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopedic Surgery,
Westchester Medical Center, Valhalla, NY, USA
| | - Joseph N. Liu
- Department of Orthopedic Surgery, Loma
Linda Medical Center, Loma Linda, CA, USA
| | - Hao-Hua Wu
- Department of Orthopedic Surgery,
University of California–San Francisco, San Francisco, CA, USA
| | - Irene L. Kalbian
- The Rothman Institute at Thomas
Jefferson University, Philadelphia, PA, USA
| | | | - Beth E. Shubin Stein
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, NY, USA,Beth E. Shubin Stein, Department of
Orthopedic Surgery, Hospital for Special Surgery, Sports Medicine and Shoulder
Service, 535 East 70th Street, New York, NY 10021, USA.
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Lansdown DA, Christian D, Madden B, Redondo M, Farr J, Cole BJ, Yanke AB. The Sagittal Tibial Tubercle-Trochlear Groove Distance as a Measurement of Sagittal Imbalance in Patients with Symptomatic Patellofemoral Chondral Lesions. Cartilage 2021; 13:449S-455S. [PMID: 31965819 PMCID: PMC8808873 DOI: 10.1177/1947603519900802] [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] [Indexed: 11/17/2022] Open
Abstract
Objective. To measure the sagittal alignment of the tibial tubercle through the sagittal tibial tubercle-trochlear groove (sTTTG) distance in patients with and without patellar chondral lesions. Design. Patients treated with patellofemoral cartilage restoration or repair procedures were retrospectively reviewed (group 1; N = 17). A control group of patients (group 2; N = 20) undergoing partial meniscectomy with normal patellar cartilage was included. An asymptomatic patellar chondrosis group (group 3; N = 15) was identified as patients undergoing partial meniscectomy with patellar cartilage wear. The sTTTG was measured on the preoperative axial T2 magnetic resonance imaging (MRI) sequence. The first point was the nadir of the anterior trochlear cartilage, and the second point was the anterior tibial tubercle. A line was drawn between these points, perpendicular to the posterior condylar axis. Comparisons were made between the 3 groups using analysis of variance testing with Bonferroni corrections. Significance was defined as P < 0.05. Results. The mean sTTTG was significantly more posterior in group 1 (5.9 ± 5.5 mm posterior to the trochlear groove) relative to group 2 (0.8 ± 5.3 mm posterior; P = 0.018). The mean value for group 3 (2.7 ± 5.3 mm posterior) fell between group 1 and 3 but was not significantly different from group 1 (P = 0.31) or group 2 (P = 0.89). There were no significant differences with regards to sulcus angle, Caton-Deschamps Index, TTTG, or knee flexion angle on the MRI scan. Conclusions. A more posteriorly positioned tibial tubercle was observed in patients with patellar cartilage lesions relative to those with intact patellar cartilage. Intermediate positioning was observed in patients with asymptomatic patellar chondral wear. Level of Evidence. Level 3 diagnostic study.
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Affiliation(s)
- Drew A. Lansdown
- Department of Orthopedic Surgery,
University of California, San Francisco, San Francisco, CA, USA,Drew A. Lansdown, Department of Orthopedic
Surgery, University of California, San Francisco, 1500 Owens Street, Suite 170,
San Francisco, CA 94158, USA.
| | - David Christian
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Brett Madden
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Michael Redondo
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | | | - Brian J. Cole
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Adam B. Yanke
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
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Chamorro-Moriana G, Perez-Cabezas V, Espuny-Ruiz F, Torres-Enamorado D, Ridao-Fernández C. Assessing knee functionality: systematic review of validated outcome measures. Ann Phys Rehabil Med 2021; 65:101608. [PMID: 34808424 DOI: 10.1016/j.rehab.2021.101608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 08/10/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Functional rating scales allow clinicians to document and quantify alterations and progression of recovery processes. There is neither awareness of numerous knee scales nor are they easy to find or compare to select the most suitable. OBJECTIVES We aimed to compile validated knee functional rating tools and analyse the methodological quality of their validation studies. Also, we aimed to provide an operational document of the outcome measures addressing descriptions of parameters, implementations, instructions, interpretations and languages, to identify the most appropriate for future interventions. METHODS A systematic review involved a search of PubMed, Web of Science, CINAHL, Scopus, and Dialnet databases from inception through September 2020. The main inclusion criteria were available functional rating scales/questionnaires/indexes for knees and validation studies. Methodological quality was analyzed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement Instruments Risk of Bias (COSMIN-RB). RESULTS We selected 73 studies. The studies investigated 41 knee rating tools (general, 46%, and specific, 54%) and 71 validations, including 29,742 individuals with knee disorders. QUADAS-2 obtained the best results in patient selection and index test (applicability section). COSMIN-RB showed the highest quality in construct validity (most analyzed metric property). The specific tools were mainly designed for prosthesis and patellofemoral and anterior cruciate ligament injuries. More considered issues were specific function (93%), especially gait, pain/sensitivity (81%), and physical activity/sports (56%). CONCLUSIONS AND IMPLICATIONS We conducted a necessary, useful, unlimited-by-time and feasible compilation of validated tools for assessing knee functional recovery. The methodological quality of the validations was limited. The best validations were for the Copenhagen Knee Range of Motion Scale in osteoarthritis and arthroplasties, Knee Outcome Survey Activities of Daily Living and Lysholm Knee Score for general knee disorders and the Tegner Activity Score for anterior cruciate ligament injuries. The operational document for the scales provides necessary data to identify the most appropriate.
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Gardner EC, Molho DA, Fulkerson JP. Coronal Malalignment-When and How to Perform a Tibial Tubercle Osteotomy. Clin Sports Med 2021; 41:15-26. [PMID: 34782071 DOI: 10.1016/j.csm.2021.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coronal malalignment of the patellofemoral joint may contribute to both instability as well as pain and joint overload. The use of distal realignment procedures has evolved to include uniplanar and multiplanar osteotomies, which allows patient-specific treatment. With a careful understanding of the complex pathoanatomy, including osseous, soft tissue, and dynamic muscular factors, an appropriately designed tibial tubercle osteotomy (TTO) is an invaluable tool for the orthopedic surgeon to improve joint biomechanics and off-load articular injuries. Current techniques have improved TTO surgery to limit complications and produce reliably good results.
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Affiliation(s)
- Elizabeth C Gardner
- Department of Orthopaedic Surgery and Rehabilitation, Yale University, Yale University School of Medicine, 47 College Street, New Haven, CT 06510, USA.
| | - David A Molho
- Department of Orthopaedic Surgery and Rehabilitation, Yale University, Yale University School of Medicine, 47 College Street, New Haven, CT 06510, USA. https://twitter.com/TotalHipKnee
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University, Yale University School of Medicine, 47 College Street, New Haven, CT 06510, USA. https://twitter.com/patelladoc
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Tibial tubercle osteotomy for patellofemoral malalignment and chondral disease provided good outcomes: A systematic review. J ISAKOS 2021; 7:78-86. [DOI: 10.1016/j.jisako.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Outcomes of MPFL reconstruction with tibial tubercle transfer for recurrent patellar instability with high grade trochlear dysplasia in Indian population. J Clin Orthop Trauma 2021; 20:101490. [PMID: 34290957 PMCID: PMC8274292 DOI: 10.1016/j.jcot.2021.101490] [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: 06/04/2021] [Revised: 06/27/2021] [Accepted: 06/27/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patellar instability is a painful condition which affects the quality of life and mobility of young individuals. The aim of this study is to observe the results of medial patello-femoral ligament reconstruction with hamstring autograft along with a modified Fulkerson osteotomy, for recurrent instability of patella with high-grade trochlear dysplasia in Indian population. MATERIALS & METHODS We conducted a prospective observational study of 26 knees (21 patients) who attended our outpatient department from June 2014 to February 2019, with recurrent instability of the patella and high-grade trochlear dysplasia. All knees were treated with MPFL reconstruction with hamstring autograft and modified Fulkerson osteotomy. RESULTS The mean follow-up period was 30 months (range: 24-50). The mean Lysholm scores improved from 49.9 (range: 30-63) preoperatively to 82.5 (range: 51-100) (p < 0.05), Kujala scores from 55.5 (36-67) to 85.9 (55-100) and International Knee Documentation Committee (IKDC) scores from 50.2 (31.6-62.3) to 82.9 (54.7-98.3) (p < 0.05) at 2 years follow-up. TT-TG distance decreased from 21.2 mm (18-25) to 11.6 mm (10-13) (p < 0.05) and patellar tilt angle decreased from 24.2° (18°-35°) to 7.2° (5°-10°) (p < 0.05). One knee had superficial skin infection in immediate post-operative period. Three knees had postoperative stiffness, which improved on manipulation under anesthesia. Six knees had implant irritation from the osteotomy screws which were removed after bony union was achieved. Functional scores were low in two knees due to patello-femoral pain, but they did not have recurrent instability. CONCLUSION MPFL reconstruction with tibial tubercle transfer gives good functional outcomes in 92.3% patients with recurrent patellar instability, associated with high-grade trochlear dysplasia in Indian population.
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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.
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35
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Song YF, Wang HJ, Yan X, Yuan FZ, Xu BB, Chen YR, Ye J, Fan BS, Yu JK. Tibial Tubercle Osteotomy May Not Provide Additional Benefit in Treating Patellar Dislocation With Increased Tibial Tuberosity-Trochlear Groove Distance: A Systematic Review. Arthroscopy 2021; 37:1670-1679.e1. [PMID: 33359817 DOI: 10.1016/j.arthro.2020.12.210] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the indications and outcomes of medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tubercle osteotomy (TTO) in treating recurrent or habitual patellar dislocation with an increased tibial tuberosity-trochlear groove (TT-TG) distance. METHODS We performed a literature search of the established medical databases Cochrane Central, PubMed-MEDLINE, EMBASE, and Web of Science. The inclusion criteria were as follows: skeletally mature patients with recurrent or habitual patellar dislocation and an increased TT-TG distance, treatment with MPFLR combined with a TTO procedure or isolated MPFLR, and reporting of clinical outcomes and complications. Each study was assessed for quality and the level of evidence. The general characteristics, indications, surgical techniques, TT-TG distance, clinical results, imaging evaluation findings, and complications of each study were recorded. RESULTS Nine studies consisting of 288 knees met the inclusion criteria. The average Coleman score was 71.56 (range, 55-83). The threshold for an increased TT-TG distance ranged from 16 to 20 mm in the included studies. Similar good postoperative outcomes were reported in patients with an increased TT-TG distance treated with MPFLR with versus without a TTO procedure. The mean postoperative Lysholm score ranged from 75.0 to 94.7 (I2 = 87.6%) in the isolated MPFLR group and from 85.0 to 87.6 (I2 = 16.3%) in the TTO-with-MPFLR group. Similar postoperative congruence angles were reported in both groups. The postoperative redislocation rate ranged from 0% to 4.2% in the TTO-with-MPFLR group, and no redislocation was found in the isolated MPFLR group. The postoperative apprehension sign was only reported in isolated MPFLR patients. CONCLUSIONS The outcomes of MPFLR with or without TTO to treat recurrent or habitual patellar dislocation with an increased TT-TG distance appeared similar. However, this study was limited by the considerable heterogeneity, variety of techniques, variety of TT-TG distances, and variability in patella alta and trochlear dysplasia among the included studies. LEVEL OF EVIDENCE Level IV, systematic review of Level II to IV studies.
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Affiliation(s)
- Yi-Fan Song
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Hai-Jun Wang
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xin Yan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Fu-Zhen Yuan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Bing-Bing Xu
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - You-Rong Chen
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Jing Ye
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Bao-Shi Fan
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Jia-Kuo Yu
- Knee Surgery Department, Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China.
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Abstract
Optimal treatment of patients with patellofemoral trochlear dysplasia and recurrent patellar instability requires in-depth understanding of this complex structural anomaly. An extensive review of the literature suggests that dysplasia occurs as a result of aberrant forces applied to the patellofemoral joint in the majority of cases. Evidence supports surgical stabilization that reconstructs the medial patellofemoral and/or medial quadriceps tendon-femoral ligament without added trochleoplasty in the majority of patients with trochlear dysplasia and recurrent patellar instability. Adding tibial tubercle transfer distally, medially, or anteromedially in those who need it to treat specific deficits in alignment or articular cartilage can be beneficial in selected patients with trochlear dysplasia and recurrent patellar instability. Trochleoplasty may be appropriate in those few cases in which permanent stable patellofemoral tracking cannot be restored otherwise, but the indications are not yet clear, particularly as trochleoplasty adds risk to the articular cartilage. Improved understanding of imaging techniques and 3-dimensional reproductions of dysplastic patellofemoral joints are useful in surgical planning for patients with recurrent patellar instability and trochlear dysplasia.
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Affiliation(s)
- Benjamin J Levy
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, UConn Health, Farmington, Connecticut, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John P Fulkerson
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, Yale University, New Haven, Connecticut, USA
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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.
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Bastos R, Wascher D, Fiquet C, Fulkerson JP, Espregueira-Mendes J, Neyret P. Review of Trillat, Dejour and Couette on ‘Diagnosis and treatment of recurrent dislocations of the patella‘. J ISAKOS 2020. [DOI: 10.1136/jisakos-2020-000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lu Y, Wang G, Hu B, Ren C, Sun L, Wang Z, He C, Xue H, Li Z, Zhang K, Ma T, Wang Q. Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures. J Orthop Surg Res 2020; 15:422. [PMID: 32943096 PMCID: PMC7500032 DOI: 10.1186/s13018-020-01960-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background This study aimed to analyze and compare the clinical and functional outcomes of distal tibia fractures treated with intramedullary nailing (IMN) using the suprapatellar (SP) and infrapatellar (IP) surgical approaches. Methods A retrospective analysis was performed in 63 patients with distal fractures that were treated with IMN between August 2014 and August 2018. A total of 27 and 36 patients underwent IMN using the SP and IP techniques, respectively. The surgical time, blood loss, closed reduction rate, rate of adjuvant reduction technique, fracture healing time, and complications were reviewed in this study. Anterior knee pain was assessed using the visual analog scale. The Lysholm Knee Scoring Scale and American Orthopaedic Foot and Ankle Society (AOFAS) scale were used as clinical measurements. Results A total of 63 patients, with a minimum follow-up of 12 months, were evaluated. The average surgical time, blood loss, rate of adjuvant reduction technique, closed reduction rate, fracture healing time, and Lysholm Knee Scoring Scale score were insignificantly different (P > 0.05) between the two groups. However, the SP approach was superior to the IP approach in terms of pain score, AOFAS score, and fracture deformity rate (P < 0.05). Conclusions In the treatment of distal tibia fractures, the SP IMN technique is associated with a significantly higher functional outcome, lower knee pain, and lower rate of fracture deformity than the IP IMN technique.
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Affiliation(s)
- Yao Lu
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China.,Bioinspired Engineering and Biomechanics Center (BEBC), School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Gen Wang
- Orthopaedics Institute of Chinese PLA, 80th Hospital, 3770 Beigongxijie, Weifang, Shandong Province, China
| | - Bin Hu
- Department of Hematology, Xi'an Gao Xin Hospital, Xi'an, 710054, Shaan'xi Province, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Liang Sun
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Zhimeng Wang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Changjun He
- Yan'an University, Yan'an, 710000, Shaanxi, China
| | - Hanzhong Xue
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Zhong Li
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Teng Ma
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China. .,Bioinspired Engineering and Biomechanics Center (BEBC), School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China.
| | - Qian Wang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China.
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van Sambeeck JDP, Rood A, Tigchelaar S, van de Groes SAW, Koëter S. Complications of a self-centering sliding tibial tubercle osteotomy for patellofemoral complaints; low incidence of non-union and fracture. Orthop Traumatol Surg Res 2020; 106:957-961. [PMID: 32753356 DOI: 10.1016/j.otsr.2020.03.020] [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: 11/20/2019] [Revised: 02/04/2020] [Accepted: 03/19/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND A tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HYPOTHESIS We hypothesize that non-union or fracture occurs in less than 1% of the procedures. PATIENTS AND METHODS Five hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow-up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy non-union, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. RESULTS The major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thrombo-embolism (VTE). CONCLUSION A self-centering TTO is a relatively safe technique with a low number of non-union and fracture. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Jordy D P van Sambeeck
- Department of orthopaedic surgery, Canisius-Wilhelmina Ziekenhuis, Postbus 9015, 6500 Nijmegen, GS, The Netherlands.
| | - Akkie Rood
- Department of orthopaedic surgery, Canisius-Wilhelmina Ziekenhuis, Postbus 9015, 6500 Nijmegen, GS, The Netherlands
| | - Siebren Tigchelaar
- Department of orthopaedic surgery, Canisius-Wilhelmina Ziekenhuis, Postbus 9015, 6500 Nijmegen, GS, The Netherlands
| | | | - Sander Koëter
- Department of orthopaedic surgery, Canisius-Wilhelmina Ziekenhuis, Postbus 9015, 6500 Nijmegen, GS, The Netherlands
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Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Oshima T. Long-term clinical results of the crosse de hockey procedure for recurrent patellar dislocation. J Orthop Surg (Hong Kong) 2020; 27:2309499019832396. [PMID: 30803315 DOI: 10.1177/2309499019832396] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A gold standard procedure has not been established for recurrent patellar dislocation because of multifactorial etiologies. We have been performing crosse de hockey procedure, which is a combination of medial and anterior transfer of the tibial tuberosity, in our institution since 1993. This study aimed to investigate the long-term clinical results of this procedure. MATERIALS AND METHODS A total of 19 patients (21 knees) underwent the crosse de hockey procedure for recurrent patellar dislocation. Of these patients, four were lost to follow-up. The remaining 17 knees in 15 patients (5 male and 10 female) were included in this study. The mean follow-up period was 13.2 years (range: 5-22.6 years). Clinical evaluation was performed using the Kujala score. Radiographic indicators, such as modified Insall-Salvati ratio, sulcus angle, congruence angle, tilting angle, lateral shift ratio, and the progression of patellofemoral osteoarthritis (OA), were measured. RESULTS Positive apprehension sign and redislocation were not observed in any of the patients. The mean Kujala score was significantly improved from 36.5 ± 18.0 preoperatively to 92.6 ± 9.9 at the final follow-up. Definite OA (a grade 2 or more using the Iwano grading system) was not observed in the patellofemoral joint at the final follow-up. CONCLUSIONS The crosse de hockey procedure showed satisfactory long-term clinical results for recurrent patellar dislocation. This procedure could prevent the progression of patellofemoral OA because of the unloading effect of the patellofemoral joint by anteromedial transfer of the tibial tuberosity.
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Affiliation(s)
- Kenichi Goshima
- 1 Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Takeshi Sawaguchi
- 1 Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Kenji Shigemoto
- 1 Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Shintaro Iwai
- 1 Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Takeshi Oshima
- 2 Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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Eliasberg CD, Diduch DR, Strickland SM. Failure of Patellofemoral Joint Preservation. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2019.150715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rood A, van Sambeeck J, Koëter S, van Kampen A, van de Groes SAW. A detaching, V-shaped tibial tubercle osteotomy is a safe procedure with a low complication rate. Arch Orthop Trauma Surg 2020; 140:1867-1872. [PMID: 32112160 PMCID: PMC7674346 DOI: 10.1007/s00402-020-03375-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION In patients with recurrent patellar dislocations, a tibial tubercle osteotomy (TTO) can be indicated to correct patella alta or an increased trochlear groove-tibial tubercle distance. Several surgical techniques are described. Previous studies emphasize that detaching osteotomies results in devascularisation, which can lead to non-union and tibial shaft fractures. The aim of this study was to report the complication rates directly related to the surgical technique of a V-shaped TTO, where the tubercle is completely released from its periosteum using a step-cut osteotomy. METHODS The retrospective case series comprised a large cohort of 263 knees with patella alta in 203 patients who underwent a V-shaped TTO, with or without additional realignment procedures, between March 2004 and October 2017. Data were obtained from available patient files. Complications were defined as minor or major. RESULTS Thirteen major complications were registered (4.9%) including two tibial fractures (0.75%) and one non-union (0.37%). Five complications (1.9%) were defined as minor. Removal of the screws because of irritation or pain was seen in 22 cases (8.2%). CONCLUSION A V-shaped TTO is a safe procedure. The presumed higher risk for tibial fractures or pseudo-arthrosis could not be confirmed.
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Affiliation(s)
- Akkie Rood
- Department of Orthopaedics, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6500 HB Nijmegen, The Netherlands
| | - Jordy van Sambeeck
- Department of Orthopaedics, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Sander Koëter
- Department of Orthopaedics, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Albert van Kampen
- Department of Orthopaedics, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6500 HB Nijmegen, The Netherlands
| | - Sebastiaan A. W. van de Groes
- Department of Orthopaedics, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6500 HB Nijmegen, The Netherlands
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Anteroposterior distance between the tibial tuberosity and trochlear groove in patients with patellar instability. Knee 2019; 26:1278-1285. [PMID: 31668910 DOI: 10.1016/j.knee.2019.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/03/2019] [Accepted: 08/25/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our objective was to describe a measurement to assess sagittal tibial tuberosity (TT)-trochlear groove (TG) distance and to compare this between asymptomatic (control) patients and patients with symptomatic patellar instability. METHODS We compared static CT images of 22 fully extended knees of patients with symptomatic patellar instability with images of 22 asymptomatic knees. TT-TG distance was measured to quantify lateralization of the TT, and anteroposterior TT-TG distance was used to quantify the sagittal distance between these two points. Lateral trochlear inclination, sulcus angle, and trochlear depth were measured. Groups were compared using paired t tests (alpha = 0.05). Correlations of anteroposterior TT-TG distance with lateral trochlear inclination, sulcus angle, and trochlear depth were assessed using linear and multivariate regression. RESULTS Mean TT-TG distances were 19.9 ± 4.4 mm (symptomatic) and 16.8 ± 5.5 mm (control) (mean ± std deviation) (P = 0.002). Mean anteroposterior TT-TG distances were 8.3 ± 7.8 mm (symptomatic) and -0.5 ± 4.6 mm (control) (P < 0.0001). The symptomatic group had greater measurements of trochlear dysplasia, with lower lateral trochlear inclination, greater sulcus angle, and lower trochlear depth (all P < 0.0001). Anteroposterior TT-TG distance and trochlear depth were strongly negatively correlated (r = 0.62, R2 = 0.39, P < 0.0001). CONCLUSIONS In asymptomatic patients, the anteroposterior TT-TG distance was -0.5 mm, indicating that the TG and TT were nearly in the same coronal plane. In patients with symptomatic patellar instability, the TG was almost nine millimeters anterior, and this distance correlated with measurements of trochlear dysplasia. LEVEL OF EVIDENCE III, case control study.
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Donoso R, Figueroa D, Espinoza J, Yañez C, Saavedra J. Osteochondral Autologous Transplantation for Treating Patellar High-Grade Chondral Defects: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119876618. [PMID: 31667196 PMCID: PMC6798165 DOI: 10.1177/2325967119876618] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Patellar cartilage defects account for 34.6% of defects found during routine
arthroscopy. These defects pose a challenge in orthopaedic surgery because
they have been associated with worse outcomes after surgical repair compared
with other chondral lesions within the knee. Purpose: To systematically review the literature for evidence on results of
osteochondral autologous transplantation (OAT) for the management of
isolated patellar cartilage high-grade defects (International Cartilage
Repair Society [ICRS] grade 3-4). Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed to find studies that
addressed outcomes regarding OAT to treat patellar high-grade cartilage
defects (ICRS grade 3-4). Studies addressing patient-reported outcomes,
return to sports, or magnetic resonance imaging (MRI) at follow-up after
isolated OAT procedures for patellar cartilage defects were included. Results: A total of 5 studies were included in this review. We were not able to
perform a meta-analysis as no studies had available data. A total of 102
patients who received an isolated OAT for a patellar chondral defect were
included in these 5 studies. All patients showed significant improvement at
final follow-up based on the following patient-reported outcome scores:
Lysholm, International Knee Documentation Committee, Kujala, Tegner, and
36-Item Short Form Health Survey. We found that 4 studies used MRI during
the first postoperative year to assess osteochondral plug integration and
positioning. The results demonstrated that most plugs were integrated and
correctly positioned when evaluated at follow-up, conducted on average after
12 months. Whether patients were able to return to sports was queried in 2
of the included studies, revealing that patients could return to their
previous level in most cases (Tegner score, 5-9 at 2 years after
surgery). Conclusion: Results indicate that OAT is a safe and reliable technique to treat patellar
high-grade osteochondral defects, allowing for significant improvement in
patient-reported outcomes and return to sports.
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Affiliation(s)
- Rodrigo Donoso
- Department of Orthopedic Surgery, Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - David Figueroa
- Department of Orthopedic Surgery, Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Jaime Espinoza
- Department of Orthopedic Surgery, Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Claudio Yañez
- Department of Orthopedic Surgery, Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Jamil Saavedra
- Investigation performed at Clínica Alemana de Santiago, Santiago, Chile
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Clouthier A, Borschneck D, Thelen DG, Deluzio K, Rainbow MJ. Relationship Between Lateral Patellar Stability Following Tibial Tubercle Osteotomy for Varying Patellofemoral Geometries. J Biomech Eng 2019; 141:1065796. [PMID: 31628469 DOI: 10.1115/1.4045231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 01/17/2023]
Abstract
The geometry of the patellofemoral joint affects function and pathology. However, the impact of trochlear groove depth on treatments for patellar instability and pain is not clear. Tibial tubercle osteotomy is a common surgical intervention for patellar instability where the tibial insertion of the patellar tendon is translated to align the extensor mechanism and stabilize the joint. The aim of this work was to investigate the interaction between trochlear groove depth and patellar tendon insertion and their effect on patellar stability. Patellofemoral geometry was modified based on a statistical shape model to create knees with a range of trochlear groove depths. A Monte Carlo approach was used and 750 instances of a musculoskeletal model were generated with varying geometry and anterior and medial transfer of the patellar tendon. Stability was assessed by applying a lateral perturbation force to the patella during simulation of overground walking. In knees with deep trochlear grooves, a medialized patellar tendon increased stability. However, in knees with shallow trochlear grooves, stability was maximized for tendon insertion ~1 mm medial to its neutral location. This patellar tendon insertion also corresponded to the best alignment of the patella in the trochlear groove in these knees, indicating that good alignment may be important to maximizing stability. Anterior patellar tendon transfer had minimal effect on stability for all geometries. A better understanding of the effects of articular geometry and tubercle location on stability may aid clinicians in patient-specific surgical planning.
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Affiliation(s)
- Allison Clouthier
- School of Human Kinetics, University of Ottawa, 75 Laurier Ave. E, Ottawa, Ontario, K1N 6N5, Canada
| | - Daniel Borschneck
- Department of Surgery, Kingston General Hospital, 76 Stuart St., Kingston, Ontario, K7L 2V7, Canada
| | - Darryl G Thelen
- Department of Mechanical Engineering, University of Wisconsin-Madison, 1513 University Ave., Madison, Wisconsin, 53706, USA
| | - Kevin Deluzio
- Department of Mechanical and Materials Engineering, Queen's University, 130 Stuart St., Kingston, Ontario, K7L 3N6, Canada
| | - Michael J Rainbow
- Department of Mechanical and Materials Engineering, Queen's University, 130 Stuart St., Kingston, Ontario, K7L 3N6, Canada
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MacDonald DRW, Caba-Doussoux P, Carnegie CA, Escriba I, Forward DP, Graf M, Johnstone AJ. Tibial nailing using a suprapatellar rather than an infrapatellar approach significantly reduces anterior knee pain postoperatively: a multicentre clinical trial. Bone Joint J 2019; 101-B:1138-1143. [PMID: 31474148 DOI: 10.1302/0301-620x.101b9.bjj-2018-1115.r2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches. PATIENTS AND METHODS A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test - Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain. RESULTS A total of 53 patients were randomized to a suprapatellar approach and 42 to an infrapatellar approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared with the uninjured leg when kneeling in the suprapatellar group compared with the infrapatellar group at all timepoints at all follow-up visits. This reached significance at four months for all timepoints except 30 seconds. It also reached significance at six months at 0 seconds, and for one year at 60 seconds. CONCLUSION The suprapatellar surgical approach for antegrade tibial nailing is associated with less anterior knee pain postoperatively compared with the infrapatellar approach Cite this article: Bone Joint J 2019;101-B:1138-1143.
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Affiliation(s)
- D R W MacDonald
- Consultant Orthopaedic Trauma Surgeon Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - C A Carnegie
- Consultant Orthopaedic Trauma Surgeon Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - D P Forward
- Nottingham University Hospital, Nottingham, UK
| | - M Graf
- Medizinisches Zentrum StädteRegion, Aachen, Germany
| | - A J Johnstone
- Consultant Orthopaedic Trauma Surgeon Aberdeen Royal Infirmary, Aberdeen, UK
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Klinge SA, Fulkerson JP. Fifteen-Year Minimum Follow-Up of Anteromedial Tibial Tubercle Transfer for Lateral and/or Distal Patellofemoral Arthrosis. Arthroscopy 2019; 35:2146-2151. [PMID: 31272635 DOI: 10.1016/j.arthro.2019.02.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 02/17/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate a minimum 15-year clinical and radiographic follow-up after anteromedial tibial tubercle transfer (anteromedialization [AMZ]) for lateral and/or distal patellar facet arthrosis. METHODS Patients treated from 1996 to 2000 were contacted. The inclusion criteria were a minimum of 15 years' follow-up after AMZ for isolated persistent retropatellar pain related to lateral and/or distal patellar chondrosis. The exclusion criteria were clinical patellar instability, revision, and significant medial patellar facet or adjacent compartment chondrosis. The anatomic location(s) and severity of arthrosis, as well as the degree of lateral maltracking, were documented. Follow-up data included pain, activity level, and satisfaction. RESULTS Of 23 patients, 15 met the inclusion criteria. All were women (17 knees) followed up for a mean of 17.1 years (range, 15.4-18.8 years). The mean age at surgery was 29.5 years. Satisfactory results were reported in 94% of knees (16 of 17), based simply on patients' subjective evaluation of the degree of success perceived. An important criterion of satisfaction was that these patients stated they would opt to undergo surgery again under the same circumstances. For 35% of knees, patients reported engaging in recreational activities, whereas for 18%, patients were minimally active. The average pain score (range, 0-10) for 75% was 2.1, and most of these patients showed grade I or II arthrosis. Post-AMZ symptomatic medial patellar subluxation was corrected successfully in 2 patients. Removal of hardware was performed in 59% of knees, and additional procedures were required in 41%. No cases of postoperative lateral patellar instability or conversion to knee arthroplasty occurred. CONCLUSIONS Anteromedial tibial tubercle transfer without articular cartilage implantation is effective in patellofemoral joint preservation, ameliorating symptoms and facilitating active lifestyles for a minimum of 15 years to nearly 20 years in patients with lateral and/or distal patellofemoral arthrosis. For 94% of knees, patients would choose to undergo the procedure again under the same circumstances. Fifty-nine percent underwent screw removal, and 41% required additional procedures, mostly arthroscopic. No patients in this therapeutic case series underwent an arthroplasty procedure. LEVEL OF EVIDENCE Level IV, therapeutic cases series.
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Affiliation(s)
- Stephen A Klinge
- Lahey Hospital and Medical Center, Burlington, Massachusetts, U.S.A..
| | - John P Fulkerson
- Orthopedic Associates of Hartford, Farmington, Connecticut, U.S.A.; University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A
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Hiemstra LA, Page JL, Kerslake S. Patient-Reported Outcome Measures for Patellofemoral Instability: a Critical Review. Curr Rev Musculoskelet Med 2019; 12:124-137. [PMID: 30835079 PMCID: PMC6542883 DOI: 10.1007/s12178-019-09537-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this paper was to review the current psychometric properties of patient-reported outcome measures that are commonly used for patients with patellofemoral instability. This review provides evidence to guide the selection of subjective outcome measures for assessing outcomes in clinical care and research studies. RECENT FINDINGS At the present time, there are two patient-reported outcome measures that have been designed for, and tested on, large cohorts of patellofemoral instability patients, the Banff Patella Instability Instrument (BPII) and the Norwich Patellar Instability Score (NPI). The BPII is a wholistic quality of life outcome measure and the NPI is a symptom score. The use of disease-specific outcome measures such as the BPII and NPI, in combination with generic knee, functional activity, and/or psychological outcome measures that have been proven to be valid and reliable for the patellofemoral instability population, is most likely to provide a well-rounded evaluation of treatment outcomes.
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Affiliation(s)
- Laurie Anne Hiemstra
- Banff Sport Medicine, PO Box 1300, Banff, Alberta, T1L 1B3, Canada.
- Department of Surgery, University of Calgary, Calgary, Canada.
| | - Jessica L Page
- Banff Sport Medicine, PO Box 1300, Banff, Alberta, T1L 1B3, Canada
| | - Sarah Kerslake
- Banff Sport Medicine, PO Box 1300, Banff, Alberta, T1L 1B3, Canada
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Ackermann J, Mestriner AB, Shu Small KM, Sheehy E, Gomoll AH. High accuracy of the osteotomy angle can be achieved without the use of calibrated guides when performing anteromedialisation tibial tubercle osteotomy. J ISAKOS 2019. [DOI: 10.1136/jisakos-2018-000270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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