Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation

PURPOSE

Patellar dislocation usually occurs to the lateral side, leading to ruptures of the medial patellofemoral ligament (MPFL) in about 90 % of all cases. Reliable prognostic factors for the stability of the patellofemoral joint after MPFL surgery and satisfaction of the patient have not been established as yet.

METHODS

This multicentric study retrospectively included 40 patients with a mean age of 22.4 ± 8.1 years (range 9-48) from 5 German Trauma Departments with first-time traumatic patellar dislocation and operative treatment. Surgery was limited to soft tissue repairs, and a preoperative magnetic resonance imaging (MRI) was performed in all cases. Evaluation of the MRI included sulcus angle, dysplasia of the trochlea, depth and facet asymmetry of the trochlea, Insall-Salvati index, Tibial tuberosity to trochlear groove (TTTG) distance, and rupture patterns of the MPFL. Patients were interrogated after 2 years about recurrent dislocation, satisfaction, and the Kujala score.

RESULTS

Trochlea facet asymmetry was significantly lower in patients with redislocation (23.5 ± 18.8) than in patients without redislocation (43.1 ± 16.5, p = 0.03). Patients with a patellar-based rupture were significantly younger (19.5 ± 7.2 years) than patients without patellar-based rupture (25.4 ± 8.1 years, p < 0.02). Patients with femoral-based ruptures were significantly older (25.7 ± 9.2 years) than patients without femoral-based rupture (19.7 ± 6.1 years, p < 0.02), and had a significantly higher TTTG distance (10.2 ± 6.9 vs. 4.5 ± 5.5, p < 0.02). Patients with incomplete ruptures of the MPFL had a significantly lower Insall-Salvati index (1.2 ± 0.2 vs. 1.4 ± 0.2, p = 0.05). The Kujala score in patients with redislocations was significantly lower (81.0 ± 10.5 points) than in patients without redislocation (91.9 ± 9.2 points, p < 0.02).

CONCLUSION

Younger patients more often sustain patellar-based ruptures following first-time traumatic patella dislocation, while older patients more often sustain femoral-based ruptures of the MPFL. Incomplete MPFL ruptures are correlated with lower Insall-Salvati indices. Low trochlear facet asymmetry is correlated with higher rates of redislocation. These results may be of relevance for the operative and postoperative treatment in the future.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial

INTRODUCTION

Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Even though several prognostic factors for patellofemoral instability have been identified so far, the appropriate therapy for patients with patellar dislocation remains a controversial issue. The purpose of this study was to compare the outcome after conservative or operative treatment in patients after first-time patellar dislocation.

PATIENTS AND METHODS

This randomized controlled clinical trial was designed multicentric including patients from six German orthopaedic and trauma departments. Twenty patients with a mean age of 24.6 years with first-time traumatic patella dislocation were included and randomized into either a conservative arm or an operative arm. Plain X-ray images of the knee joint (a.p. and lateral view and tangential view of both patellae) were performed in all cases prior to therapy to exclude osteochondral fragments requiring refixation. An MRI was recommended, but not compulsory. Patients were consulted after 6, 12, and 24 months with a questionnaire including the criteria of the Kujala score, recurrent dislocation, and satisfaction.

RESULTS

The mean Kujala score of the conservative vs operative treatment group was 78.6 vs 80.3 after 6 months (p = 0.842), 79.9 vs 88.9 after 12 months (p = 0.165), and 81.3 vs 87.5 after 24 months (p = 0.339). Redislocation rate after 24 months was 37.5 % in the conservative group and 16.7 % in the operative group (p = 0.347). Due to the small number of patients that could be included, no significant difference between the groups could be detected. We see a tendency towards better results after operative treatment.

CONCLUSION

Our multicentric prospective randomized controlled trial revealed no significant difference between conservative and operative treatment for patients after first-time traumatic patellar dislocation. However, a tendency towards a better Kujala score and lower redislocation rates for patients with operative treatment was observed. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A meta-analysis including other study's level I data is desirable for the future.

[Therapeutic concept for injuries of the lower cervical spine]

Over a period of two and half years, the Spinal Surgery Working Group of the Deutsche Gesellschaft für Unfallchirurgie (German Association for Trauma Surgery) DGU has carried out a prospective study of relevant injuries of the cervical vertebral column in 544 patients. The lower section C3 to Th1 of the cervical vertebral column was affected in 308 cases (56 per cent). The injuries of the cervical vertebral column were caused primarily by accidents in road traffic and in the pursuit of recreational activities. More than half of the patients had multiple injuries. The share of degenerative concomitant changes as a cause for relevant injuries increased with age considerably. In case of a qualified trauma with the suspicion of an injury, the immobilisation of the cervical vertebral column has to be retained until the X-ray diagnosis inclusive of a computer tomography has been completed as this is obligatory for the clarification of suspected findings or for pre-operative planning, respectively. The diagnostic range is complemented by guided function imaging to reveal instabilities, and magnetic resonance imaging, which has to be carried out in case any X-ray pathology is absent and neurological functional deficit exists. Patients with neurological deficits, which were found in 43 per cent of the cases suffering from injuries of the lower cervical vertebral column, should be treated as quickly as possible with a high dose of methyl prednisolone. A recovery of the neurological abolition by at least one ASIA level was observed in 10 per cent of the patients concerned. A conservative therapy with a cervical collar was pursued in 24 per cent of the cases with stable injuries. An operative treatment indication, which was diagnosed in 76 per cent of the cases, aims at the early recovery of the anatomy with decompression of the spinal cord, reposition, and stabilisation of segments concerned. The point of the operation was determined by the neurological status, the existing dislocation, and the increasing instability as well as the concomitant injuries. Positioning necessary for intensive medical interventions required an early stabilisation of the spinal column. The front access with plate spondylodesis as a standard procedure with various special implants has proved to be safe and reliable in the healing result. Dorsal accesses shall remain reserved for definable individual indications and should be prevented in case of injuries of the cervical medulla, if possible, to spare the cervical muscles.

Therapeutical concept for injuries of the lower cervical vertebral column

Over a period of two and half years, the Spinal Surgery Working Group of the Deutsche Gesellschaft für Unfallchirurgie (German Association for Trauma Surgery) DGU has carried out a prospective study of relevant injuries of the cervical vertebral column in 544 patients. The lower section C3 to Th1 of the cervical vertebral column was affected in 308 cases (56 per cent). The injuries of the cervical vertebral column were caused primarily by accidents in road traffic and in the pursuit of recreational activities. More than half of the patients had multiple injuries. The share of degenerative concomitant changes as a cause for relevant injuries increased with age considerably. In case of a qualified trauma with the suspicion of an injury, the immobilisation of the cervical vertebral column has to be retained until the X-ray diagnosis inclusive of a computer tomography has been completed as this is obligatory for the clarification of suspected findings or for pre-operative planning, respectively. The diagnostic range is complemented by guided function imaging to reveal instabilities, and magnetic resonance imaging, which has to be carried out in case any X-ray pathology is absent and neurological functional deficit exists. Patients with neurological deficits, which were found in 43 per cent of the cases suffering from injuries of the lower cervical vertebral column, should be treated as quickly as possible with a high dose of methyl prednisolon. A recovery of the neurological abolition by at least one ASIA level was observed in 10 per cent of the patients concerned. A conservative therapy with a cervical collar was pursued in 24 per cent of the cases with stable injuries. An operative treatment indication, which was diagnosed in 76 per cent of the cases, aims at the early recovery of the anatomy with decompression of the spinal cord, reposition, and stabilisation of segments concerned. The point of the operation was determined by the neurological status, the existing dislocation, and the increasing instability as well as the concomitant injuries. Positioning necessary for intensive medical interventions required an early stabilisation of the spinal column. The front access with plate spondylodesis as a standard procedure with various special implants has proved to be safe and reliable in the healing result. Dorsal accesses shall remain reserved for definable individual indications and should be prevented in case of injuries of the cervical medulla, if possible, to spare the cervical muscles.

[Indications for surgical management of injuries of the cervical spine]

The indication for operative treatment of serious injuries to the cervical spine is basically determinated by instability and dislocation. Timing of the operation is based on the neurological deficit. If there is a chance for recovery operative treatment is urgent. For the upper cervical spine defined indications are existing for type-2-fractures of the dens and C 2/C 3-instabilities of the hangman-type with major dislocation. Fractures of C 0 and C 1 are preferably treated by conservative methods. Only cases with compound injury patterns with a high degree of ligamentous instability may require dorsal fusion. For serious injuries of the lower cervical spine operative treatment is needed in most instances. Conservative treatment is only indicated if functional stability can be proofed and injuries to the discs and compression to the myelon are ruled out.

Extended incubation of culture plates improves recovery of Bordetella spp

Extended incubation of culture plates was studied to see if the recovery of Bordetella spp. from nasopharyngeal swabs could be improved. Forty-eight Bordetella isolates were recovered from 103 children (overall positive-culture rate, 46.6%) who met the clinical case definition of pertussis. Seven of 44 (16%) B. pertussis isolates and 2 of 4 (50%) B. parapertussis isolates were recovered only after extended incubation of nasopharyngeal cultures up to 12 days.

Role of the immune response in interstitial cystitis

Interstitial cystitis (IC) patients present with irritative and painful bladder symptoms and are diagnosed clinically by their symptoms, negative urine cultures, absence of other diseases, and cytoscopic findings of glomerulations and/or ulcers. The histological evaluation usually is described as nonspecific chronic inflammation. Although numerous theories of pathogenesis have been proposed, the etiology of IC is unknown. The hypothesized causes of IC include infectious, lymphovascular obstruction and neurogenic, endocrinologic, psychoneurotic, inflammatory (especially mast cells), and autoimmune pathologies. In this Review we discuss the evidence supporting a role for autoimmunity in IC and link the mast cell to the expression of the disease. Moreover, we discuss newly developed animal models that may provide insight into the etiology of IC.