Internal Torsion of the Knee: An Embodiment of Lower-Extremity Malrotation in Patients with Patellar Instability

Promising results following derotational femoral osteotomy in patellofemoral instability with increased femoral anteversion: A systematic review on current indications, outcomes and complication rate

Purpose

Patellofemoral joint instability (PFJI) can surgically be treated with a multitude of approaches, depending on the underlying pathology. In the presence of increased femoral anteversion, some authors have reported good results with a derotational distal femoral osteotomy (DeDFO). The purpose of the study was to investigate the indications, outcomes and complication rate of DeDFO for PFJI.

Methods

A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching Medline, Embase, Web of Science and Cochrane Library databases through 1 December 2023. Included were levels 1-4 clinical studies of skeletally mature patients undergoing a DeDFO for PFJI irrespective of concomitant procedures. Study characteristics, indications, radiological and clinical outcomes, surgical technique and concomitant procedures, re-dislocation and complication rate were all analysed, as was methodological quality.

Results

A total of 12 studies including 310 patients (325 knees) were included. Three studies were cohort studies, all others were case series. The mean patient age across the studies was 22 years, and the mean follow-up was 29.4 months. Femoral anteversion cut-off was between 20° and 30°. Every study included at least one concurrent soft tissue, bony or combined procedure. Across all studies, one case of re-dislocation was reported (0.3%) and four implant or osteotomy-related complications (1.2%) were reported. All studies reported a statistically significant increase in clinical scores.

Conclusion

This systematic review of DeDFO for patellofemoral instability in the presence of increased femoral anteversion demonstrates promising clinical results and an extremely low dislocation and complication rate. The heterogeneity of the cut-off in anteversion and concomitant procedures, especially tibial tubercle osteotomy with seemingly identical results, indicates the need for high-quality evidence for treating patellofemoral instability. Based upon this systematic review, we strongly recommend that DeDFO be added to the 'menu à la carte' of PFJI.

Level of Evidence

Level III Systematic Review.

Double-Level Knee Derotational Osteotomy Yields Better Postoperative Outcomes Than Tibial Tubercle Transfer Combined With Medial Patellofemoral Ligament Reconstruction in Patients With Recurrent Patellar Instability and Severe Malrotation

PURPOSE

To assess the postoperative outcomes of double-level knee derotational osteotomy (KDRO) combined with medial patellofemoral ligament reconstruction (MPFLR) and to compare it with tibial tuber transfer (TTT) and MPFLR without derotational osteotomy in patients with recurrent patellar instability and a marked torsional deformity.

METHODS

From March 2020 to December 2021, patients with torsion deformity (combined femoral torsion [FT] and tibial torsion [TTn] ≥30°) were retrospectively included. The minimum follow-up time was 18 months. Patients who received KDRO and MPFLR were categorized as the KDRO group and patients who received a combined TTT and MPFLR were categorized as the control group. Preoperative and postoperative clinical symptoms, patient-reported outcomes (Kujala, visual analog scale, Lysholm, International Knee Documentation Committee, Tegner, and Knee Injury and Osteoarthritis Outcome scores), and imaging parameters (FT, TTn, patellar height, femoral trochlear dysplasia, congruence angle, patellar tilt angle, lateral patellar angle, lateral patellar translation, and tibial tubercle-trochlear groove distance) were analyzed.

RESULTS

In all, 36 patients were included with 18 in KDRO group and 18 in control group. The mean follow-up time was 30 (range 21-39) months. At the latest follow-up, no patient experienced redislocation in either group. Except for the FT and TTn in the control group, postoperative imaging parameters were significantly reduced to the normal range. KDRO group had a lower patellar tilt angle (P = .043, effect size 0.64). All clinical scores in both groups significantly improved postoperatively. The KDRO group had better functional scores than control group except the KOOS daily living activities subscore and the KOOS sports and recreation subscore. More patients in the KDRO group met the minimal clinically important difference for most patient-reported outcomes than the control group. Eight patients (44%) in the control group complained of postoperative anterior knee pain, compared with 1 patient (6%) in the KDRO group (P = .018).

CONCLUSIONS

KDRO combined with MPFLR was associated with better postoperative outcomes than TTT combined with MPFLR in patients with recurrent patellar instability and a torsion deformity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Hinge screw or no hinge stabilization provides decreased stability compared to hinge plate in a biomechanical evaluation of distal femoral derotational osteotomies

PURPOSE

Derotational distal femoral osteotomy (DFO) is the causal treatment for patients with femoral torsional deformity. The fixation is achieved by a unilateral angle-stable plate. Delayed- or non-unions are one of the main risks of the procedure. An additional contralateral fixation may benefit the outcome. Therefore, we hypothesize that primary stability in DFO can be improved by an additional fixation with a hinge screw or an internal plate.

METHODS

Derotational DFO was performed in 15 knees and fixed either with an angle-stable plate only (group 'None'), with an additional lateral screw (group 'Screw') or with an additional lateral plate (group 'Plate'). Biomechanical evaluation was carried out under axial loading of 150 N (partial weight bearing) and 800 N (full weight bearing), followed by internal and external rotation. After linear axial loading in step 1, a cyclic torsional load of 5 Nm was applied under constant axial load in step 2. In step 3, the specimens were unloaded. Micromovements between the distal and proximal parts of the osteotomy were recorded at each step for all specimens.

RESULTS

In step 1, the extent of micromovements was highest in group 'None' and lowest in group 'Plate' without being significantly different. In step 2, group 'Plate' showed significantly higher stability, reflected by less rotation and lower micromovements. Increasing the axial load from 150 to 800 N at step 2 resulted in increased stability in all groups but only reached significance in group 'None'.

CONCLUSION

An additional contralateral plate significantly increased stability in derotational DFO compared to the unilateral angle-stable plate only. Contrary, a contralateral hinge screw did not provide improved stability.

STUDY DESIGN

Experimental study.

LEVEL OF EVIDENCE

IV.

Computed tomography-based automated 3D measurement of femoral version: Validation against standard 2D measurements in symptomatic patients

To validate 3D methods for femoral version measurement, we asked: (1) Can a fully automated segmentation of the entire femur and 3D measurement of femoral version using a neck based method and a head-shaft based method be performed? (2) How do automatic 3D-based computed tomography (CT) measurements of femoral version compare to the most commonly used 2D-based measurements utilizing four different landmarks? Retrospective study (May 2017 to June 2018) evaluating 45 symptomatic patients (57 hips, mean age 18.7 ± 5.1 years) undergoing pelvic and femoral CT. Femoral version was assessed using four previously described methods (Lee, Reikeras, Tomczak, and Murphy). Fully-automated segmentation yielded 3D femur models used to measure femoral version via femoral neck- and head-shaft approaches. Mean femoral version with 95% confidence intervals, and intraclass correlation coefficients were calculated, and Bland-Altman analysis was performed. Automatic 3D segmentation was highly accurate, with mean dice coefficients of 0.98 ± 0.03 and 0.97 ± 0.02 for femur/pelvis, respectively. Mean difference between 3D head-shaft- (27.4 ± 16.6°) and 3D neck methods (12.9 ± 13.7°) was 14.5 ± 10.7° (p < 0.001). The 3D neck method was closer to the proximal Lee (-2.4 ± 5.9°, -4.4 to 0.5°, p = 0.009) and Reikeras (2 ± 5.6°, 95% CI: 0.2 to 3.8°, p = 0.03) methods. The 3D head-shaft method was closer to the distal Tomczak (-1.3 ± 7.5°, 95% CI: -3.8 to 1.1°, p = 0.57) and Murphy (1.5 ± 5.4°, -0.3 to 3.3°, p = 0.12) methods. Automatic 3D neck-based-/head-shaft methods yielded femoral version angles comparable to the proximal/distal 2D-based methods, when applying fully-automated segmentations.

Clinical outcomes of derotational femoral osteotomy combined with medial patellofemoral ligament reconstruction in patients with patellar dislocation and increased femoral anteversion unaffected by the pattern of distribution of femoral torsion

PURPOSE

The aim of this study was to evaluate the clinical effect of derotational femoral osteotomy combined with medial patellofemoral ligament reconstruction for patellar dislocation and the effect of the distribution of femoral torsion at different segments on postoperative function.

METHODS

Forty-two patients with patellar dislocation who underwent derotational femoral osteotomy from 2017 to 2021 were retrospectively analysed. All patients received computed tomography scans from the hip to the knee to evaluate correction of the femoral anteversion (FA) angle, patellar tilt angle (PTA) and congruence angle (CA) after derotational femoral osteotomy. Subjective scores, such as the Kujala, Lysholm, International Knee Documentation Committee (IKDC), Tegner and visual analog scale (VAS) scores, were used to evaluate knee function before and after the operation. Patients with supracondylar torsion > distal torsion were categorized into the supracondylar torsion group and patients with distal torsion > supracondylar torsion were categorized into the distal torsion group. Subgroup analyses were performed.

RESULTS

No presentation of redislocation occurred in these patients at the minimum 2-year follow-up visit. The mean preoperative FA angle in the supracondylar torsion group was 30.2° ± 4.2°, and the mean postoperative FA angle was 14.5° ± 2.5° (p < 0.001). The mean preoperative FA angle was 26.7° ± 1.4° and the mean postoperative FA angle was 14.1° ± 1.4° in the distal torsion group. In addition, postoperative PTA and CA were significantly corrected in both groups (p < 0.001). The postoperative Kujala, Lysholm, IKDC, Tegner and VAS scores were significantly improved in both groups (p < 0.001). Subgroup analyses showed a higher preoperative FA in the supracondylar torsion group and a higher occurrence of high-grade trochlear dysplasia in the distal torsion group. However, there was no significant difference in their postoperative clinical outcomes.

CONCLUSION

Through a minimum of 2-year follow-up visits of patients with patellar dislocation and increased FA, it was found that derotational femoral osteotomy could significantly reduce FA and improve subjective knee function. The pattern of torsion distribution did not significantly affect the clinical outcomes of derotational femoral osteotomy. These findings readvised orthopaedic surgeons that derotational femoral osteotomy remains the preferred procedure for correcting rotational malalignment, but that they should be more cautious about its indications.

LEVEL OF EVIDENCE

Level IV.

Distal femoral torsion is correlated with higher-grade trochlear dysplasia and shorter anterior condyles in patients with patellar dislocation and increased femoral torsion

PURPOSE

To describe the characteristics of femoral torsion in patients with different segmental torsion types and to evaluate the correlations between segmental torsion and the morphology of the femoral condyles and trochlea in patients with patellar dislocation and increased femoral torsion.

METHODS

Between January 2021 and March 2023, 69 patients were included and classified into two groups according to the femoral segment contributing the most to total torsion: 32 patients in Group A (femoral neck and shaft torsion) and 37 patients in Group B (distal torsion). Trochlear dysplasia was evaluated using Dejour's classification and sulcus angle. The morphology of the femoral condyles was evaluated using the lengths and ratios of the medial and lateral condyles. Correlations between femoral torsion and morphology were evaluated.

RESULTS

Total torsion was significantly correlated with femoral neck and shaft torsion (r = 0.882, P < 0.001) and distal torsion (r  = 0.262, P = 0.030). Femoral neck and shaft torsion was significantly increased with increasing total torsion. The trochlear sulcus was flatter and more dysplastic, and the anterior condyles were shorter in Group B. Distal torsion was significantly correlated with the lengths of the medial and lateral anterior condyles (r  = - 0.567, P < 0.001; r = -0.701, P < 0.001), sulcus angle (r  = 0.611, P < 0.001) and Dejour trochlea type (r  = 0.512, P = 0.001), while femoral neck and shaft torsion showed no correlations.

CONCLUSION

Femoral torsion is a complex of femoral neck and shaft torsion and distal torsion, especially femoral neck and shaft torsion. Distal torsion was significantly correlated with a flatter trochlear sulcus, higher-grade trochlear dysplasia, and shorter anterior condyles. The new findings highlighted the importance of the segmental evaluation of femoral torsion, which would facilitate understanding of the anatomical characteristics of femoral torsion in patients with patellar dislocation and increased femoral torsion and may lead to improvement in the surgical options regarding femoral torsion.

LEVEL OF EVIDENCE

Level III.

Effect of Lower Extremity Torsion on Clinical Outcomes After Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer for Recurrent Patellofemoral Instability

BACKGROUND

Increased femoral torsion (FT) or tibial torsion (TT) has been suggested to be a potential risk factor for recurrent patellofemoral instability. However, the influence of increased FT or TT on the postoperative clinical outcomes of recurrent patellofemoral instability has rarely been investigated.

PURPOSE

To assess the effect of increased FT or TT on postoperative results in patients with recurrent patellofemoral instability after combined medial patellofemoral ligament reconstruction (MPFLR) and tibial tubercle transfer, along with the influence of other risk factors.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Out of 91 patients, the study's analyses included 86 patients with recurrent patellofemoral instability who were treated with MPFLR and tibial tubercle transfer and enrolled between April 2020 and January 2021. FT and TT were assessed using preoperative computed tomography images. According to the torsion value of FT or TT, patients were categorized into 3 groups for each of FT and TT: group A (<20°), group B (20°-30°), and group C (>30°). Patellar height, femoral trochlear dysplasia, and the tibial tuberosity-trochlear groove (TT-TG) distance were also assessed. Patient-reported outcome scores (Tegner, Kujala, International Knee Documentation Committee [IKDC], Lysholm, and Knee injury and Osteoarthritis Outcome Score [KOOS]) were evaluated pre- and postoperatively. Clinical failure of MPFLR was recorded. Subgroup analysis was conducted to evaluate the effect of increased FT or TT on the postoperative outcomes.

RESULTS

A total of 86 patients were enrolled with a median follow-up time of 25 months. At the final follow-up, all functional scores improved significantly. Patella alta, high-grade trochlear dysplasia, and increased TT-TG distance did not have any significant effect on the postoperative functional scores. Regarding FT, subgroup analysis indicated that all functional scores of group C were lower than those of groups A and B except the KOOS knee-related Quality of Life score. For TT, group C had lower scores than group A for all functional outcomes except Tegner and KOOS Quality of Life and lower scores than group B for Kujala, IKDC, KOOS (Symptoms and Sport and Recreation subscales), Tegner, and Lysholm scores. The comparison between group A and group B, whether for FT or TT, revealed no significant differences.

CONCLUSION

For patients with recurrent patellofemoral instability, increased lower extremity torsion (FT or TT >30°) was associated with inferior postoperative clinical outcomes after combined MPFLR and tibial tubercle transfer.

Local torsion of distal femur is a risk factor for patellar dislocation

PURPOSE

It has been widely reported that femoral anteversion is a risk factor for patellar dislocation. This study aims to evaluate whether internal torsion of the distal femur is noticeable in patients without increased femoral anteversion and to assess whether it is a risk factor for patellar dislocation.

METHODS

A retrospective analysis was conducted on 35 patients (24 females, 11 males) with recurrent patellar dislocation but without increased femoral anteversion treated in our hospital from January 2019 to August 2020. All patients underwent knee X-rays, digital radiography of lower-limbs, and CT scans of hip, knee, and ankle joints to measure femoral anteversion angle, distal femoral torsion angle, TT-TG and Caton-Deschamps index. Thirty-five control cases were matched on age and sex to compare the difference of anatomic parameters between the two groups, and the logistic analysis was used to analyze risk factors for patellar dislocation. Perman correlation coefficient was used to evaluate the correlation among femoral anteversion, distal femoral torsion and TT-TG.

RESULTS

Greater distal femoral torsion was still observed in patients with patellar dislocation but without increased femoral anteversion. The torsion angle of distal femur, TT-TG distance and incidence of Patella Alta in patients with patellar dislocation were greater than those in control group, and the inter-group differences were statistically significant (P < 0.05). The torsion angle of distal femur (OR = 2.848, P < 0.001), TT-TG distance (OR = 1.163, P = 0.021) and Patella Alta (OR = 3.545, P = 0.034) were risk factors for patellar dislocation. However, no significant correlation was found among femoral anteversion, distal femoral torsion and TT-TG in patients with patellar dislocation.

CONCLUSION

On the condition that femoral anteversion did not increase, increased distal femoral torsion was commonly observed in patients with patellar dislocation, which represents an independent risk factor for patellar dislocation.

Study on the correlation between the severity of patellofemoral arthritis and the morphology of the distal femur

PURPOSE

Distal femoral torsion is a key factor for poor alignment of patellofemoral joint. This study aims to evaluate the correlation between distal femoral torsion and the severity of patellofemoral arthritis, and to analyze the correlation between distal femoral torsion and the morphology of femoral condyle.

METHODS

A retrospective analysis was performed on 125 patients awaiting surgical treatment for knee osteoarthritis from January 2021 to March 2022(79 females, 46 males, average age: 65.78 years, SD 6.61). All patients underwent knee joint radiography, lower-limb digital radiography, and knee joint CT scans. The ratio of length of each distal femoral condyle, TT-TG, patellar tilt, DFL-PCL, DFL-TEA, TEA-PCL and TEA-ACL were measured. The Pearson correlation coefficient was used to evaluate the correlation between distal femoral torsion and ratio of distal femoral condyle, TT-TG and patellar tilt. Logistic regression was used to evaluate the correlation between each parameter and the severity of PFOA.

RESULTS

With the increased severity of PFOA, TT-TG, patellar tilt, DFL-PCL, DFL-TEA and PCA all tended to increase. Patellar tilt was correlated with DFL-PCL (r = 0.243) and TEA-PCL(r = 0.201), but TT-TG had no evident correlation with distal femoral torsion. Compared with Grade I patients of PFOA, DFL-PCL, DFL-TEA, and TEA-PCL were risk factors for increased severity of patellofemoral arthritis in Grade III patients of PFOA, but there was no significant statistic difference in Grade II patients of PFOA.

CONCLUSIONS

Distal femoral torsion correlates with the severity of patellofemoral arthritis. Variation of the femoral transepicondylar axis caused by the change of ratio of the femoral condyle is particularly important in the distal femoral torsion. In patients with severe PFOA, abnormal variation of the femoral condyle axis should be not ignored.

High prevalence of increased posterior tibial slope in ACL revision surgery demands a patient-specific approach

PURPOSE

To determine the prevalence of an "increased posterior tibial slope (PTS)" (PTS ≥ 12°) in a population with one, two or ≥ three anterior cruciate ligament (ACL) graft insufficiencies. Furthermore, to investigate whether the prevalence of an increased PTS and the absolute PTS increases with an increasing number of ACL graft insufficiencies, as well as to determine the survival time of the first ACL graft.

METHODS

Patients diagnosed with an ACL graft insufficiency between January 2021 and March 2022 were included. The PTS was measured using the proximal anatomical tibial axis on long lateral knee radiographs. Patients were divided into 3 groups depending on the number of ACL graft insufficiencies: group A (1 graft insufficiency), group B (2 graft insufficiencies) and group C (≥ 3 graft insufficiencies). The prevalence of increased PTS and absolute PTS between groups was compared alongside the survival of the first ACL graft between patients with or without increased PTS.

RESULTS

Two-hundred and six patients (147 males/59 females) met the inclusion criteria. 73 patients showed an increased PTS [prevalence 35% [95% confidence interval (CI) (29%; 42%)]. 155 patients were found in category A, 42 patients in B and 9 patients in C. The prevalence of increased PTS for group A, B and C was, 32% [95% CI (25%; 40%)], 38% [95% CI (23%; 53%)] and 78% [95% CI (51%; 100%)], respectively. The prevalence of increased PTS and mean PTS did not increase significantly between group A and B. However, both parameters increased significantly between group A and C, and group B and C (p < 0.05). The survival time of the first ACL graft in patients with or without an increased PTS was 3 (interquartile range (IQR) 5) and 6 years (IQR 9), respectively (p < 0.05).

CONCLUSION

There is a 35% prevalence of increased PTS in the studied ACL graft insufficient patient cohort. The survival of the first ACL graft is shorter in patients with an increased PTS. Surgeons should be aware of the high prevalence of increased PTS when consulting patients for revision ACL reconstruction as it is an important risk factor for recurrent instability.

Medial patellofemoral ligament reconstruction combined with derotational distal femoral osteotomy yields better outcomes than isolated procedures in patellar dislocation with increased femoral anteversion

PURPOSE

The purpose of this study was to evaluate and compare clinical and radiological outcomes between isolated medial patellofemoral ligament reconstruction (MPFLR) and MPFLR combined with derotational distal femoral osteotomy (DDFO) for patellar dislocation with increased femoral anteversion (FA).

METHODS

Between 2014 and 2019, 36 patients who underwent isolated MPFLR and 31 patients who underwent MPFLR combined with DDFO were retrospectively included. Clinical outcomes included physical examinations, functional outcomes (Kujala, Lysholm, International Knee Documentation Committee (IKDC), and Banff Patella Instability Instrument (BPII) scores), activity level (Tegner activity score and return to sports), complications, and patellar re-dislocation rate. Radiological outcomes included patella tilt angle, patellar congruence angle, and patella-trochlear groove distance.

RESULTS

All clinical outcomes improved significantly in both groups, but the DDFO group had significantly better postoperative scores than the MPFLR group (Kujala: 85.1 ± 7.7 vs. 80.5 ± 8.4, P = 0.023; Lysholm: 86.8 ± 8.2 vs. 81.9 ± 9.1, P = 0.026; IKDC: 86.2 ± 10.0 vs. 81.7 ± 8.1, P = 0.045; and BPII: 68.0 ± 12.5 vs. 62.3 ± 10.0, P = 0.039). Both groups achieved successful return to sports (90.3% vs. 91.7%). No re-dislocation or major complications occurred. Radiological outcomes improved significantly in both groups, but the DDFO group had better outcomes (P < 0.05). The tibial tubercle-trochlear groove distance was only improved after DDFO from 17.0 ± 2.3 mm to 15.1 ± 2.0 mm (P = 0.001).

CONCLUSION

Both isolated MPFLR and MPFLR combined with DDFO yielded satisfactory clinical and radiological outcomes in the treatment of patellar dislocation with increased FA. However, combined DDFO had better outcomes and should be considered a priority.

LEVEL OF EVIDENCE

Level III.

Axial orientation of the femoral trochlea is superior to femoral anteversion for predicting patellar instability

PURPOSE

The femoral anteversion angle is considered to be the same as femoral torsion; however, the femoral anteversion angle is strongly influenced by the femoral posterior condylar morphology. It remains unclear whether the femoral anteversion angle and axial orientation of the femoral trochlea can predict patellar instability. This study aimed to redefine the femoral inherent torsion, verify whether the femoral anteversion angle reflects the femoral inherent torsion, and compare the validity and calculate the cut-off values of the femoral anteversion angle and femoral trochlear axial orientation for predicting patellar instability.

METHODS

Seventy-three patients with patellar instability and 73 matched controls underwent computed tomography to measure the femoral anteversion angle, femoral inherent torsion, and femoral trochlear axial orientation. Pearson's product moment correlation coefficients and linear regression were calculated to determine correlations between measurements. Receiver operating characteristic curves and nomograms were plotted to evaluate the predictive validity of the femoral anteversion angle and femoral trochlear axial orientation for patellar instability.

RESULTS

All measurements showed excellent intra- and inter-observer reliability. Compared with the control group, the patellar instability group had a significantly larger femoral anteversion angle (25.4 ± 6.4° vs. 20.2 ± 4.5°) and femoral inherent torsion (18.3 ± 6.7° vs. 15.8 ± 3.4°), and significantly smaller femoral trochlear axial orientation (58.1 ± 7.3° vs. 66.9 ± 5.1°). The femoral anteversion angle and femoral trochlear axial orientation had area under the receiver operating characteristic curve values of 79 and 84%, respectively, and cut-off values of 24.5° and 62.7°, respectively. The calibration curve and decision curve analysis showed that the femoral trochlear axial orientation performed better than the femoral anteversion angle in predicting patellar instability. There was a strong correlation between the femoral anteversion angle and femoral inherent torsion (r > 0.8). Linear regression analysis of the femoral inherent torsion with the femoral anteversion angle as the prediction variate showed moderate goodness-of-fit (adjusted R² = 0.69).

CONCLUSION

The femoral anteversion angle moderately reflects the femoral inherent torsion. The femoral trochlear axial orientation is better than the femoral anteversion in predicting patellar instability in terms of predictive efficiency, consistency with reality, and net clinical benefit. These findings warn orthopaedists against overstating the role of the femoral anteversion angle in patellar instability, and suggest that the femoral trochlear axial orientation could aid in identifying at-risk patients and developing surgical strategies for patellar instability.

LEVEL OF EVIDENCE

III.