Evaluation of the modified Elmslie-Trillat procedure for patellofemoral dysfunction

Effects of Lateral Patellar Retinaculum Release for Recurrent Patella Dislocation: A Prospective Study

Purpose

Recurrent patellar dislocation (RPD) is the most common complication of patellar instability and the medial patellofemoral ligament (MPFL) reconstruction has become its reference treatment. Lateral patellar retinaculum (LPR) release used to be performed in association with MPFL reconstruction. The aim of this study was to investigate the added values of MPFL reconstruction plus LPR release for RPD.

Methods

After Institutional Review Board approval, RPD patients from October 2014 to April 2019 were randomly assigned into two groups (isolated MPFL reconstruction [Group I] and MPFL reconstruction plus LPR release [Group II]) and prospectively assessed until 12 months after surgery. Knee joints with flexion of 20° were scanned by a 64-row CT scanner. Congruence angle (CA), patella tilt angle (PTA), lateral patellofemoral angle (LPFA), tibial tuberosity-trochlear groove distance and patellar tilt with the quadriceps relaxed and contracted were measured. Knee function was assessed by Lysholm knee score and International Knee Documentation Committee (IKDC) score. Patients were followed up for at least 12 months.

Results

A total of 87 RPD patients (45 for Group I and 42 for Group II) were selected in this study. Preoperative clinical characteristics were not significantly different across groups. No serious complications were noted in either group. It was statistically insignificant between the two group patients in terms of postoperative patella associated measurements (P > 0.05 for all). The Lysholm score and IKDC score of Group I (84.5 ± 7.1 and 87.9 ± 7.2) were significantly less than that of Group II (89.7 ± 8.7 and 93.1 ± 7.7), which indicated the better knee function of Group II.

Conclusion

LPR release plus MPFL reconstruction provides additional benefits compared with isolated MPFL reconstruction in knee function. A combination of surgical treatments for RPD should be recommended.

Comparative study of three different combination surgical methods for recurrent patella dislocation

PURPOSE

The effects of different combination of surgical techniques for recurrent patella dislocation (RPD) remain unclear. Thus, aim of this study was to investigate the surgical outcomes of different combination of surgical techniques for RPD.

METHODS

The clinical data of 79 patients with RPD from August 2014 to October 2016 were analysed retrospectively. Knee joint was assessed according to measurements of the congruence angle (CA), patellar tilt angle (PTA) and lateral patellofemoral angle (LPFA). Knee function was evaluated by Kujala patellofemoral score, Lysholm knee score and Tegner score. Patients were followed up by out-patient examination and telephone till October 2018.

RESULTS

Preoperative clinical characteristics were similar across groups. It was statistically insignificant among three groups in CA, PTA, LPFA and redislocation rate. In term of knee functions, the MPFL reconstruction and LPR release group had the highest score (Lysholm score: 91.82 ± 4.64, Kujala score: 94.22 ± 4.26, Tegner score: 5.80 ± 1.00, respectively) and the LPR release and MPR plication had the lowest score (Lysholm score: 78.10 ± 6.90, Kujala score: 80.91 ± 4.30, Tegner score: 4.98 ± 1.22, respectively).

CONCLUSION

Three combinations of surgical methods were similar in terms of postoperative joint congruence and redislocation rate, but MPFL reconstruction combined with LPR release is worthy to be promoted with the highest knee function scores.

Distal alignment procedures for patellofemoral instability: comprehensive review of the literature

Patellofemoral disorders are a common cause of complaint in adolescent patients. Several distal realignment procedures performed in isolation or combination with proximal alignment have been described. To clarify the role of distal alignment for patellofemoral instability, a systematic review of the literature was conducted. Two independent reviewers accessed the following databases: PubMed, Medline, CINAHL, Cochrane, EMBASE and Google Scholar. A total of 1478 patients with a mean age of 22.78 years were included. The mean follow-up was 86.53 months. The average Kujala score improved from 57.66 to 82.73. The average Lysholm score improved from 63.25 to 87.87, and the average Tegner score from 3 to 4.16. VAS score improved from an average 8 to 2.56. We account a total of 46 major complications, 45 minor complications and 95 recurrences. The risk of a recurrence is 6.42%. A total of 122 additional surgeries were performed during the follow-up. This systematic review of literature suggests the importance to identify the pathological background that predisposes patients for developing patellofemoral instability and its implications for the decision-making process. The optimal treatment for patellofemoral instability should be individualized to address the specific anatomical abnormalities that contribute to patellofemoral dislocations. Distal alignments are a feasible solution to restore correct patellar biomechanics and tracking, leading to an improvement of patients' quality of life.

National Athletic Trainers' Association Position Statement: Management of Individuals With Patellofemoral Pain

OBJECTIVE: 

To present recommendations for athletic trainers and other health care providers regarding the identification of risk factors for and management of individuals with patellofemoral pain (PFP).

BACKGROUND: 

Patellofemoral pain is one of the most common knee diagnoses; however, this condition continues to be one of the most challenging to manage. Recent evidence has suggested that certain risk factors may contribute to the development of PFP. Early identification of risk factors may allow clinicians to develop and implement programs aimed at reducing the incidence of this condition. To date, clinicians have used various treatment strategies that have not necessarily benefitted all patients. Suboptimal outcomes may reflect the need to integrate clinical practice with scientific evidence to facilitate clinical decision making.

RECOMMENDATIONS: 

The recommendations are based on the best available evidence. They are intended to give athletic trainers and other health care professionals a framework for identifying risk factors for and managing patients with PFP.

Evaluation of different surgical methods in treating recurrent patella dislocation after three-dimensional reconstruction

PURPOSE

Recurrent patella dislocation (RPD) is the most common complication of patellar instability. The effects of different surgical techniques on the outcome of RPD treatments remain unclear. This study was conducted to compare the effects of three surgical techniques in treating RPD by three-dimensional (3D) reconstruction from computed tomography (CT) scans.

METHODS

Sixty-eight patients with RPD and no previous surgical treatments who attended our hospital between October 2010 and 2013 were enrolled and randomly assigned into three groups: (1) medial patellofemoral ligament (MPFL) reconstruction and medial patellar retinaculum (MPR) plication group; (2) lateral patellar retinaculum (LPR) release and MPR plication group; and (3) MPFL reconstruction and LPR release group. Knee joints with flexion of 20° were scanned by a 64-row CT scanner and 3D reconstructed. Congruence angle (CA), patellar tilt angle (PTA), lateral patellofemoral angle (LPFA), and congruence of the lateral patellofemoral articular surface were measured. Knee joint function was evaluated by the Lysholm knee scoring scale, Kujala patellofemoral score, and International Knee Documentation Committee (IKDC) score.

RESULTS

Pre-operative clinical characteristics were similar across groups. After treatment, the CA, PTA, and LPFA were reverted to normal post-operatively without statistically significant between-group differences. The MPFL reconstruction and LPR release group had the highest congruence of the lateral patellofemoral articular surface; while the (LPR) release and (MPR) plication group had the lowest Lysholm knee scoring scale, Kujala patellofemoral score, and IKDC score after surgery.

CONCLUSIONS

The MPFL reconstruction and LPR release group had the best clinical outcomes among the three surgical methods, as indicated by better joint congruence after 3D joint reconstruction and higher knee function scores.

The Relationship of Static Tibial Tubercle-Trochlear Groove Measurement and Dynamic Patellar Tracking

BACKGROUND

The tibial tubercle to trochlear groove (TT-TG) distance is used for screening patients with a variety of patellofemoral joint disorders to determine who may benefit from patellar medialization using a tibial tubercle osteotomy. Clinically, the TT-TG distance is predominately based on static imaging with the knee in full extension; however, the predictive ability of this measure for dynamic patellar tracking patterns is unknown.

PURPOSE

To determine whether the static TT-TG distance can predict dynamic lateral displacement of the patella.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

The static TT-TG distance was measured at full extension for 70 skeletally mature subjects with (n = 32) and without (n = 38) patellofemoral pain. The dynamic patellar tracking patterns were assessed from approximately 45° to 0° of knee flexion by use of dynamic cine-phase contrast magnetic resonance imaging. For each subject, the value of dynamic lateral tracking corresponding to the exact knee angle measured in the static images for that subject was identified. Linear regression analysis determined the predictive ability of static TT-TG distance for dynamic patellar lateral displacement for each cohort.

RESULTS

The static TT-TG distance measured with the knee in full extension cannot accurately predict dynamic lateral displacement of the patella. There was weak predictive ability among subjects with patellofemoral pain ( r² = 0.18, P = .02) and no predictive capability among controls. Among subjects with patellofemoral pain and static TT-TG distances 15 mm or more, 8 of 13 subjects (62%) demonstrated neutral or medial patellar tracking patterns.

CONCLUSION

The static TT-TG distance cannot accurately predict dynamic lateral displacement of the patella. A large percentage of patients with patellofemoral pain and pathologically large TT-TG distances may have neutral to medial maltracking patterns.

Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and Other Distal Realignment Procedures for the Management of Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature

PURPOSE

To evaluate clinical outcomes, rate of recurrence, and complications following distal realignment procedures (Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures) performed alone or in combination with proximal procedures for the management of patellar dislocation.

METHODS

A systematic literature review was performed following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A search in PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patellar," "dislocation," "tibial transfer," "Elmslie-Trillat," "Roux Goldthwait," "tibial tubercle osteotomy," "Fulkerson," "Maquet," "procedure," "clinical," and "outcome."

RESULTS

Thirty-eight articles were included in the systematic review. A total of 1,182 knees belonging to 1,023 patients were grouped according to the duration of the follow-up period. The overall rate of recurrence was 7% (83 of 1,182 knees). Approximately 5.3% (28 of 520 knees) of the redislocation occurred in the short-medium term, and 8.3% (55 of 662 knees) occurred in the long-term.

CONCLUSIONS

Distal realignment procedures performed alone or in combination with proximal procedures for the management of patellar dislocation have shown good clinical outcomes and a low rate of recurrence highlighting the efficacy of these procedures. To date no randomized controlled clinical trials are available on the topic.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Correlation of the tibial tuberosity-trochlear groove distance with the Q-angle

PURPOSE

The Q-angle has been used for years to quantify lateralization of the patella. The tibial tuberosity-trochlea groove distance (TT-TG distance) was introduced to analyse patellar tracking. Does a significant correlation exist between these two parameters? Do other significant interrelations exist between the Q-angle/TT-TG distance, torsion of the femur and tibia, the frontal axis, overall leg length, gender, former patellar dislocation, BMI?

METHODS

One hundred knees in 55 patients with patellofemoral symptoms were included in a prospective study. All patients underwent clinical examination, including measurement of the Q-angle. A torsional CT was obtained from all patients.

RESULTS

The correlation coefficient was 0.33/0.34 (left/right leg), showing that the TT-TG distance tends to rise in direct ratio to a rising Q-angle. Thus, a significant correlation was found (p = 0.017). Femoral and tibial torsion had a positive effect on the TT-TG distance, but showed no significant correlation. Leg length had a significant effect on the TT-TG distance (p = 0.04). The frontal axis had a nonsignificant influence on the Q-angle or TT-TG distance. On average, the Q-angle in women was 2.38° greater than it was in men, but the difference was not significant.

CONCLUSION

A significant correlation was noted between the Q-angle and the TT-TG distance. Both depend on various parameters and must be assessed for the analysis of patellofemoral maltracking. The Q-angle did not differ significantly between men and women; thus, the conclusion is that no different ranges need not be used.

LEVEL OF EVIDENCE

Diagnostic study, Level III.

The Incidence of Complications of Tibial Tubercle Osteotomy: A Systematic Review

PURPOSE

The goal of this review was to quantify the risk of perioperative and early postoperative complications of tibial tubercle osteotomy (TTO) with different techniques.

METHODS

A systematic review of multiple databases was performed to identify studies that reported complications of TTO. Complications were defined as any adverse outcome, including osteotomy site nonunion, fracture, infection, wound complications, neurovascular complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Major complications were defined as nonunion, fracture, infections/wound complications requiring return to the operating room, and DVT or PE. The risk of subsequent hardware removal was also quantified.

RESULTS

The 19 identified studies included a total of 787 TTOs: 472 direct medialization procedures (Elmslie-Trillat technique), 193 anteromedialization procedures (Fulkerson technique), and 102 procedures in which the tibial tubercle was completely detached for medialization or distalization, or a combination. The overall complication risk was 4.6%. The risk of complications was higher when the tibial tubercle was completely detached (10.7%) than with Elmslie-Trillat (3.3%) or Fulkerson (3.7%) procedures (P = .004). The overall risk of major complications was 3.0%. Hardware removal was performed in 36.7% of osteotomies and was less frequent with the Elmslie-Trillat technique (26.8%) than with the Fulkerson technique (49.0%) or complete tubercle detachment (48.3%) (P < .001).

CONCLUSIONS

Tibial tubercle osteotomy is a complex surgical procedure with a significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

The results of adductor magnus tenodesis in adolescents with recurrent patellar dislocation

Recurrent dislocation of the patella is a common orthopaedic problem which occurs in about 44% of cases after first-time dislocation. In most cases of first-time patellar dislocation, the medial patellofemoral ligament (MPFL) becomes damaged. Between 2010 and 2012, 33 children and adolescents (39 knees) with recurrent patellar dislocation were treated with MPFL reconstruction using the adductor magnus tendon. The aim of our study is to assess the effectiveness of this surgical procedure. The outcomes were evaluated functionally (Lysholm knee scale, the Kujala Anterior Knee Pain Scale, and isokinetic examination) and radiographically (Caton index, sulcus angle, congruence angle, and patellofemoral angle). Four patients demonstrated redislocation with MPFL graft failure, despite the fact that patellar tracking was found to be normal before the injury, and the patients had not reported any symptoms. Statistically significant improvements in Lysholm and Kujala scales, in patellofemoral and congruence angle, were seen (P < 0.001). A statistically significant improvement in the peak torque of the quadriceps muscle and flexor was observed for 60°/sec and 180°/sec angular velocities (P = 0.01). Our results confirm the efficacy of MPFL reconstruction using the adductor magnus tendon in children and adolescents with recurrent patellar dislocation.

Medial Patellofemoral Ligament Reconstruction for Patellar Dislocation: A Systematic Review

Background:

With improved understanding of the biomechanical importance of the medial patellofemoral ligament (MPFL), its reconstruction for patellar dislocation has become increasingly popular. The aim of this systematic review was to critically determine the effectiveness of MPFL reconstruction for patellar dislocation.

Hypothesis:

MPFL reconstruction for patellar dislocation leads to a low redislocation rate with improved Kujala scores.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using Embase and Medline (Ovid) databases. Inclusion criteria included first-time and recurrent patellar dislocation, subluxation, or persistent instability with a minimum follow-up of 12 months and documentation of postoperative redislocation rate or Kujala score. The studies were systematically appraised, and a meta-analysis was performed.

Results:

Twenty-two studies were included: 2 randomized controlled trials, 3 parallel case series, and 17 case series. There were a total of 655 knees in the review, with an age range at time of surgery from 11 to 52 years. The pooled postoperative redislocation rate from all 17 case series showed a mean of 2.44%. The pooled preoperative Kujala scores from 12 case series showed a mean of 51.6 (95% CI, 46.71-56.49). The pooled postoperative Kujala scores from 16 case series showed a mean of 87.77 (95% CI, 85.15-90.39).

Conclusion:

Although the studies were of low quality, the meta-analysis of 17 case series shows that MPFL reconstruction for recurrent patellar dislocation results in a significant improvement in Kujala scores, a low redislocation rate, and acceptable complication rate. Randomized trials would be needed to draw influences on the superiority of MPFL reconstruction compared with other treatments.

Triple positioning of tibial tubercle osteotomy for patellofemoral disorders

BACKGROUND AND PURPOSE

Patellofemoral disorders are often associated with patellofemoral malalignment. Tibial tubercle transfer is an effective method to correct the patellofemoral malalignment. This study evaluated the long-term results of triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders with 10-year follow-up.

PATIENTS AND METHODS

Fifty-six patients with 62 knees underwent triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders. All patients received standard rehabilitation protocol postoperatively. The average length of follow-up was 128.5±9.8 months (range 116 to 149). The evaluations included pain score, Kujala patellofemoral score, Lysholm score and radiograph of the knee.

RESULTS

The overall clinical results were excellent in 41.9%, good in 37%, fair in 12.9% and poor in 5% at 1 year; and 29% excellent, 41% good, 18.3% fair and 9.3% poor at 10 years. Satisfactory results were 78.9% and 70.9%, and unsatisfactory results 21.1% and 29.1% at 1 year and 10 years respectively. There was no correlation of clinical outcomes with age, sex, body weight and height and preoperative pain score. However, there was a positive correlation of clinical outcomes with the improvement of the congruence angle on postoperative X-rays of the knee, and a negative correlation of clinical outcome with the severity of articular cartilage damage assessed in arthroscopy. The complications included 1 non-union and 1 infection with non-union.

CONCLUSION

Triple positioning of tibial tubercle osteotomy is effective and long lasting in patients with patellofemoral disorders with 70.9% satisfactory results at 10-year follow-up.

LEVEL OF EVIDENCE

IV (refer to instructions for detailed description on the level of evidence).

A review of the management of patellofemoral pain syndrome

OBJECTIVE

Patellofemoral pain syndrome (PFPS) is one of the most frequently diagnosed knee conditions in the primary care, orthopedic, and sports medicine settings. Although strength training and stretching programs have traditionally been the mainstay of patient treatment, there are no consensus recovery protocols for runners experiencing PFPS. The purpose of our review is to examine recent literature regarding the efficacy of various treatment modalities in the management of patients with PFPS.

METHODS

Our review included 33 articles from a PubMed literature search using the search term PFPS treatment. The search was limited to randomized controlled trials, crossover case-controlled studies, and cohort studies with ≥ 10 participants, with trial data that were published within the last 5 years.

RESULTS

Strength training and stretching exercises continue to be strongly supported by research as effective treatment options for runners with PFPS. Recent studies have confirmed that quadriceps and hip strengthening combined with stretching in a structured physiotherapy program comprise the most effective treatment for reducing knee pain symptoms and improving functionality in patients with PFPS. As previous studies have shown, therapies such as proprioceptive training, orthotics, and taping may offer benefits as adjunctive therapies but do not show a significant benefit when they are used alone in patients with PFPS. Additionally, recent research has confirmed that surgical and pharmacologic therapies are not effective for the management of patients with PFPS.

CONCLUSION

A large number of athletes are impacted by PFPS every year, particularly young runners. Sports medicine researchers have investigated many possible therapies for patients with PFPS; however, no clear guidelines have emerged regarding the management of the syndrome. Our review analyzes recent literature on PFPS and identifies specific treatment recommendations. The most effective and strongly supported treatment modality for patients with PFPS is a combined physiotherapy program, including strength training of the quadriceps and hip abductors and stretching of the quadriceps muscle group. Adjunctive therapies, including taping, biofeedback devices, and prefabricated orthotic inserts, may provide limited additive benefits in select populations. Surgery should be avoided in all patients with PFPS.

Distal realignment (tibial tuberosity transfer)

Although tibial tuberosity (TT) transfer has for many years been the basis of many protocols for the management of patellar instability, the role of pure medial transfer in particular appears to be declining. In contrast, the greater recognition of the importance of patella alta as a predisposing factor to recurrent patellar dislocation has resulted in a resurgence in the popularity of distal TT transfer. When TT transfer is performed, the direction and amount of transfer is based on the patellar height and the lateralization of the TT relative to the trochlear groove. Patellar height is best assessed on a lateral radiograph with the knee in flexion using a ratio that uses the articular surface of the patella in relation to the height above the tibia. Assessment of lateralization of the TT relative to the trochlear groove can be made using either computed tomography or magnetic resonance imaging scans.

Modern management of patellar instability

Recurrent patellofemoral instability is a disabling condition, attributed to a variety of anatomical aetiologies. Trochlear dysplasia, patella alta, an increased tibial tubercle trochlear groove distance of greater than 20 mm and soft tissue abnormalities such as a torn medial patellofemoral ligament and inadequate vastus medialis obliquus are all factors to be considered. Management of this condition remains difficult and controversial and knowledge of the functional anatomy and biomechanics of the patellofemoral joint, a detailed history and clinical examination, and an accurate patient assessment are all imperative to formulate an appropriate management plan. Surgical treatment is based on the underlying anatomical pathology with an aim to restore normal patellofemoral kinematics. We summarise aspects of assessment, treatment and outcome of patellofemoral instability and propose an algorithm of treatment.

The operative management of patella malalignment

Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment.Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness.A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.