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Bansal S, Choudhury AK, Barman S, Niraula BB, Raja BS, Kalia RB. Medial Patellofemoral Ligament Tear Associated with an Intra-articular Axial Spilt Osteochondral Fracture of the Lateral Femoral Condyle: a "Knee Trap-door" Fracture. J Orthop Case Rep 2023; 13:52-56. [PMID: 37654742 PMCID: PMC10465732 DOI: 10.13107/jocr.2023.v13.i08.3814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/21/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction Medial patellofemoral ligament (MPFL) prevents lateral dislocation of the patella and acts as a major stabilizer. The tear could be associated with osteochondral avulsion fractures; however, intra-articular split fractures are not seen. Here, we present one unusual case of such a presentation. Case Report A 16-year-old male presented with a history of recurrent patellar dislocation and inability to bear weight following the last episode. The patient was diagnosed with an MPFL tear with an unusual intra-articular femoral condyle split fracture. The case had significant improvement in functional scores post-surgery. Conclusion In physically active populations, twisting of the knee could result in an MPFL tear, leading to recurrent patellar dislocation. The treatment remains ligament reconstruction, open, or arthroscopic. Associated intra-articular fractures are very rare with such injuries and need to be addressed due to the high rate of non-union.
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Affiliation(s)
- Shivam Bansal
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Arghya Kundu Choudhury
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Saptarshi Barman
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bishwa Bandhu Niraula
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Balgovind S Raja
- Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Roop Bhushan Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Tan CMP, Zhu Y, Guo L, Loh SYJ. Medial patellofemoral ligament reconstruction with and without trochleoplasty for patients with patella instability-correlation of trochlear dysplasia and patient outcome, classification and outcome measure in the past decade-a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:595-607. [PMID: 34120236 DOI: 10.1007/s00590-021-03030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The primary aim of the study is to compare the patient outcome in medial patellofemoral ligament reconstruction (MPFLR) or MPFLR concurrent with trochleoplasty (MPFLR + TP) and correlate it with the degree of trochlear dysplasia (TD). The secondary aim is to review TD classification, outcome measure, chronological and geographical trend of such studies in the past decade. METHODS A systemic review of the literature in the past decade on studies of patients with patella instability and underwent either a MPFLR or MPFLR + TP. The degree of TD with the patient outcome was correlated and compared between the 2 groups. The TD classification, outcome measures, chronological and geographical trends of these studies were documented. RESULTS There is no statistical difference in the overall improvement in the compared outcome scores between the 2 groups. However, the MPFLR studies reported a total of 16 re-dislocation in contrast to none in the MPFLR + TP studies. The 24 selected studies in the current review utilized different TD classification as well as outcome measures. A more homogeneous subgroup of 12 studies utilized Dejour classification as well as Kujala score that enabled comparison and showed no significant difference in outcome. The highest number of MPFLR publications was in 2019 and was from North and South Americas, Asia and Europe. The MPFLR + TP studies were from Europe during 2013 to 2017. CONCLUSION Though there is an overall improvement in post-operative outcomes scores with no statistical significance between MPFLR and MPFLR + TP, the documented re-dislocations in the MPFLR studies suggested an undetermined zone where the choice of procedure could result in a different outcome. The current review did not show correlation between the degree of TD with the patient outcome to provide a clear indication for either procedure according to the degree of TD. The diverse TD classifications and varied outcome measures indicated the need for standardization and consistency in documentation to guide the treating clinician in the choice of procedure. MPFLR was more commonly performed and studied than MPFLR + TP in the past decade.
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Affiliation(s)
- Cheryl Marise Peilin Tan
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore.
| | - Yanan Zhu
- Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- , Cochrane, Singapore
| | - Liang Guo
- Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- , Cochrane, Singapore
| | - Sir Young James Loh
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
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Raja BS, Balasubramanian SG. Carta ao editor: Alterações Radiográficas Femoropatelares na insuficiência do Ligamento Cruzado Anterior. Rev Bras Ortop 2015;50(1):43–49. Rev Bras Ortop 2020; 55:504. [PMID: 32904883 PMCID: PMC7458744 DOI: 10.1055/s-0039-1700826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/23/2019] [Indexed: 10/28/2022] Open
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Alvarez O, Steensen RN, Rullkoetter PJ, Fitzpatrick CK. Computational approach to correcting joint instability in patients with recurrent patellar dislocation. J Orthop Res 2020; 38:768-776. [PMID: 31736122 DOI: 10.1002/jor.24526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 11/10/2019] [Indexed: 02/04/2023]
Abstract
Patellar dislocation is a debilitating injury common in active adolescents and young adults. Conservative treatment after initial dislocation is often recommended, but almost half of these patients continue to suffer from recurrent dislocation. The objective of this study was to compare preoperative patellofemoral joint stability with stability after a series of simulated procedures, including restorative surgery to correct to pre-injury state, generic tibial tubercle osteotomy, patient-specific reconstructive surgery to correct anatomic abnormality, less invasive patient-specific surgery, and equivalent healthy controls. Three-dimensional, subject-specific finite element models of the patellofemoral joint were developed for 28 patients with recurrent patellar dislocation. A 50 N lateral load was applied to the patella to assess the lateral stability of the patellofemoral joint at 10° intervals from 0° to 40° flexion. Medial patellofemoral ligament reconstruction, along with reconstructive procedures to correct anatomic abnormality were simulated. Of all the simulations performed, the healthy equivalent control models showed the least patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament restraining load during lateral loading tests. Isolated restorative medial patellofemoral ligament reconstruction was the surgery that resulted in the most patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament reaction force across all flexion angles. Patient-specific reconstruction to correct anatomic abnormality was the only surgical group to have non-significantly different results compared with the healthy equivalent control group across all joint stability metrics evaluated. Statement of clinical significance: This study suggests patient-specific reconstructive surgery that corrects underlying anatomic abnormalities best reproduces the joint stability of an equivalent healthy control when compared with the pre-injury state, generic tibial tubercle osteotomy, and less invasive patient-specific surgery. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:768-776, 2020.
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Affiliation(s)
- Oliver Alvarez
- Mechanical and Biomedical Engineering, Boise State University, Boise, Idaho
| | | | - Paul J Rullkoetter
- Center for Orthopaedic Biomechanics, University of Denver, Denver, Colorado
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Fitzpatrick CK, Steensen RN, Tumuluri A, Trinh T, Bentley J, Rullkoetter PJ. Computational analysis of factors contributing to patellar dislocation. J Orthop Res 2016; 34:444-53. [PMID: 26331373 DOI: 10.1002/jor.23041] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/14/2015] [Indexed: 02/04/2023]
Abstract
Treatment for an initial incidence of patellar dislocation is usually conservative management; however, almost half of patients experience a subsequent, or multiple, dislocation(s). Patients often undergo multiple procedures which fail to treat the underlying anatomic abnormalities. The objective of this study was to evaluate interactions between key predisposing anatomic factors to patellar dislocation and identify combinations of abnormal factors which increase the risk of recurrent lateral dislocation. Four factors associated with lateral patellar dislocation were identified (sulcus angle, Insall-Salvati ratio, tibial tubercle-trochlear groove distance, and femoral anteversion). A finite element model of the patellofemoral joint was developed and parameterized so that a value for each factor could be applied and the model geometry/alignment would be modified accordingly. 100 combinations of the four factors were generated in separate computational simulations and resulting kinematics and forces of the patellofemoral joint were recorded. Sulcus angle was the most impactful factor on constraint. Multiple abnormal factors were generally required to produce the extremes of patellar alignment observed in this analysis. Understanding the underlying anatomic factors, and their effect on joint mechanics, for patients with recurrent lateral patellar dislocation will aid in determining optimal treatment pathways on a patient-specific basis.
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Affiliation(s)
| | - Robert N Steensen
- Department of Orthopaedics, Mount Carmel Health System, Columbus, Ohio
| | - Aruna Tumuluri
- Center for Orthopaedic Biomechanics, University of Denver, Denver, Colorado
| | - Thai Trinh
- Department of Orthopaedics, Mount Carmel Health System, Columbus, Ohio
| | - Jared Bentley
- Department of Orthopaedics, Mount Carmel Health System, Columbus, Ohio
| | - Paul J Rullkoetter
- Center for Orthopaedic Biomechanics, University of Denver, Denver, Colorado
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Kiran KR, Srikanth IM, Chinnusamy L, Deepti K. Dynamic medial patellofemoral ligament reconstruction in recurrent patellar instability: A surgical technique. Indian J Orthop 2015; 49:630-6. [PMID: 26806970 PMCID: PMC4705729 DOI: 10.4103/0019-5413.168768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The medial patellofemoral ligament (MPFL) is the primary stabilizer of the patellofemoral joint; its reconstruction has been recommended in adults over the past decade after recurrent patellar instability. However, there has been no standardized technique for reconstruction, therefore, ideal graft and technique for reconstruction are yet undetermined. However, dynamic MPFL reconstruction studies claim to be superior to other procedures as it is more anatomical. This preliminary study aims at assessing the outcomes of MPFL reconstruction in a dynamic pattern using hamstring graft. We performed this procedure in four consecutive patients with chronic patellar instability following trauma. MPFL reconstruction was done with hamstring tendons detached distally and secured to patellar periosteum after being passed through a bony tunnel in the patella without an implant and using the medial collateral ligament as a pulley. In all 4 knees, the MPFL reconstruction was isolated and was not associated with any other realignment procedures. No recurrent episodes of dislocation or subluxation were reported at 24 months followup.
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Affiliation(s)
- Kopuri Ravi Kiran
- Department of Orthopaedics, Dr. PSIMS and RF, Chinoutpalli, India,Address for correspondence: Dr. Kopuri Ravi Kiran, D. No 54-20/7-9A, Road No: 2, SKDGO Colony, Gurunanak Nagar, Vijayawada - 520 008, Andhra Pradesh, India. E-mail:
| | - I Muni Srikanth
- Department of Orthopaedics, ASHRAM, Eluru, Andhra Pradesh, India
| | - Lenin Chinnusamy
- Department of Orthopaedics, Apolo Hospitals, Chennai, Tamil Nadu, India
| | - K Deepti
- Department of Radiodiagnosis, TIME Hospitals, Vijayawada, Andhra Pradesh, India
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Banke IJ, Kohn LM, Meidinger G, Otto A, Hensler D, Beitzel K, Imhoff AB, Schöttle PB. Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sports Traumatol Arthrosc 2014; 22:2591-8. [PMID: 23851967 DOI: 10.1007/s00167-013-2603-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 07/02/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE Excessive trochlear dysplasia may be responsible for recurrent patellofemoral instability (PFI) due to a missing bony guidance for the patella in early flexion. Thus, an isolated medial patellofemoral ligament reconstruction (MPFLR) can be insufficient, since it mainly addresses instability close to extension and additionally can increase patellofemoral pressure leading to pain in flat or convex trochlear dysplasia. Therefore, in combination with a trochleoplasty, an anatomical trochlear groove is created, resulting in patellofemoral stability also in flexion, while patellofemoral pressure is normalized. In this prospective study, we evaluated the outcome of open trochleoplasty in combination with MPFLR with a minimum follow-up of 2 years for treatment of excessive PFI. METHODS In between 2007 and 2009, 18 knees of 17 consecutive patients (mean age of 22.2 ± 4.9 years) with trochlear dysplasia type B, C or D according to Dejour et al. and positive apprehension from 0 to 60° of flexion were included. Tegner, Kujala and IKDC scores, apprehension and pain, trochlear dysplasia, sulcus angle, tibial tuberosity trochlear groove, patellar tilt and shift, Caton-Deschamps index as well as patellofemoral arthrosis according to the classification of Iwano et al. were assessed pre- and postoperatively. RESULTS At a mean of 30.5 ± 5.9 months, all but one patient were subjectively satisfied with the outcome of the procedure, all showing absence of positive apprehension or redislocation. Significant (p < 0.001) reduction in pain (5.6 to 2.5 ± 2.8 points, VAS) and increase in Tegner (2, range 0-4 points to 6, range 3-8 points), Kujala (51.1 to 87.9 ± 20.0 points) and IKDC (49.5 to 80.2 ± 21.0%) scores could be achieved. Radiologically significant (p < 0.02) improvement of patellofemoral positional parameters leading to more normal anatomy was recorded, while short-term arthrosis was absent. CONCLUSIONS Combined treatment for trochleoplasty with MPFLR serves as a successful therapy for chronic PFI. This combinatory treatment concept is a reliable option not only as salvage therapy but also as primary procedure regarding treatment for excessive PFI. LEVEL OF EVIDENCE Prospective case series, Level IV.
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Affiliation(s)
- Ingo J Banke
- Department of Orthopedic Sports Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany,
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Surgical versus non-surgical management for primary patellar dislocations: an up-to-date meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24:1513-23. [PMID: 24390042 DOI: 10.1007/s00590-013-1400-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 12/22/2022]
Abstract
The aim of this up-to-date meta-analysis was to compare the effects of surgical versus non-surgical treatment of patients following primary patellar dislocation and to provide the best evidence currently available. A comprehensive literature search was conducted using multiple databases, including Medline, Embase, and Cochrane Registry of Clinical Trials. All databases were searched from the earliest records to May 2013. Eligible studies were selected, and data were extracted by two independent investigators. The primary outcome variable was the frequency of recurrent patellar dislocation. The other outcomes included knee function scores, patient-rated outcomes, and radiographic examination. If appropriate, meta-analysis of these variables was performed. Nine independent trials were found to match the inclusion criteria. The pooled results demonstrated that the incidence of recurrent patellar dislocation and Hughston visual analog scale was significantly lower in the surgical treatment group than that in the non-surgical treatment group (P < 0.05). There was no statistically significant difference between the two treatment groups in frequency of subsequent surgical interventions, percentage of excellent or good subjective opinion, Kujala score, pain score on visual analog scale, and severity of patellofemoral joint osteoarthrosis (P > 0.05). This up-to-date meta-analysis indicates that surgical treatment was associated with a lower risk of recurrent patellar dislocation, but a lower Hughston VAS than non-surgical treatment for primary patellar dislocation. More large high-quality trials and further studies are needed to overcome the limitations of small sample sizes, and varieties of different surgical procedures or non-surgical management strategies adopted in the included trials.
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Abstract
Habitual dislocation of the patella (HDP) is a common presentation in pediatric age unlike adults. Many surgical procedures using proximal realignment and distal realignment have been reported to treat HDP in children with satisfactory results. However, late presentation of habitual patellar dislocation with osteoarthritis is rare and treatment plan has not yet been established. We present a case of neglected iatrogenic habitual patellar dislocation with osteoarthritis in a 50-year-old woman. Two-staged procedure was planned, first with patellar realignment and later with definitive total knee arthroplasty. Quadricepsplasty, medial patello-femoral ligament reconstruction, lateral release and tibial tuberosity transfer was done as primary procedure and total knee arthroplasty, which was planned as secondary procedure, was deferred as the patient improved functionally.
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Affiliation(s)
- Raghuveer K Reddy
- Department of Orthopaedics, Sai Institute of Sport Injuries and Arthroscopy, Hyderabad, India,Address for correspondence: Dr. Raghuveer K Reddy, Sai Institute of Sports Injury and Arthroscopy, Hyderabad, Andhra Pradesh, India. E-mail:
| | - Vamsi Kondreddi
- Department of Orthopedics, Mamata Medical College, Khammam, Andhra Pradesh, India
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