-
Knee Surgery, Sports Traumatology,... May 2023To assess the imaging modalities used for diagnosis, as well as the management decisions of patients with osteochondral fractures (OCF) and loose bodies following... (Review)
Review
MRI as the optimal imaging modality for assessment and management of osteochondral fractures and loose bodies following traumatic patellar dislocation: a systematic review.
PURPOSE
To assess the imaging modalities used for diagnosis, as well as the management decisions of patients with osteochondral fractures (OCF) and loose bodies following traumatic patellar dislocation.
METHODS
According to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA), MEDLINE, EMBASE, Web of Science, and PubMed were searched for results from January 1, 2000, to May 18, 2021, in two subsequent searches for English language studies that presented data on traumatic patellar dislocation. Quality of selected papers was assessed using the Methodological Index for Non-Randomised Studies (MINORS) and the Risk of Bias (RoB) 2.0 protocol. Results were qualitatively synthesised, and descriptive statistics were calculated.
RESULTS
Forty studies totalling 3074 patients (1407 females) were included for the analysis. The mean age was 18.9 years (range 0-69). The population included 2446 first-time dislocations. The imaging modalities used were: 71.1% MRI, 52.6% plain radiography, 12.1% CT, and 0.68% ultrasound. In the 25 studies that reported the number of OCF, a total of 38.3% of patients were found to have OCF. 43.3% of patients with a first-time dislocation, and 34.7% of patients with previous dislocations, had at least one OCF. In the included paediatric studies (maximum age ≤ 18), the presence of OCF was detected by plain radiography in 10.1% of patients, MRI in 76.6% of patients, and CT in 89.5% of patients. For management of an OCF, the surgical options include fixation for larger pieces, excision for smaller pieces, and conservative management on a case-by-case basis.
CONCLUSIONS
Based on the current available evidence, assessment and management of patellar dislocations and subsequent OCFs vary, with radiography and MRI as the main imaging modalities on presentation and particular benefit for MRI in the paediatric population. Findings from this study suggest the highest rate of OCF detection with MRI, and thus, surgeons should consider routinely ordering an MRI in patients with first-time patellar dislocation. Regarding management of OCFs, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. Few studies choose conservative management of OCFs due to later requirements for surgical management. Future work should focus on large, high-quality studies, and implementation of randomised control trials to form guidelines for imaging patellar dislocations and management of OCFs.
LEVEL OF EVIDENCE
Level IV.
Topics: Female; Humans; Child; Infant, Newborn; Infant; Child, Preschool; Adolescent; Young Adult; Adult; Middle Aged; Aged; Patellar Dislocation; Joint Dislocations; Magnetic Resonance Imaging; Femoral Fractures; Radiography; Intra-Articular Fractures
PubMed: 35796753
DOI: 10.1007/s00167-022-07043-x -
Orthopaedic Journal of Sports Medicine Sep 2021Medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and nonoperative treatment are important treatments for patients with patellar dislocation. However,... (Review)
Review
BACKGROUND
Medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and nonoperative treatment are important treatments for patients with patellar dislocation. However, it is unclear which treatment leads to better outcomes.
PURPOSE
To determine the efficacy and safety of the 3 treatments in the treatment of patellar dislocation and compare the effect of MPFL reconstruction with MPFL repair, MPFL reconstruction with nonoperative treatment, and MPFL repair with nonoperative treatment.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
The PubMed, Web of Science, Cochrane Library, Embase, CNKI (China National Knowledge Infrastructure), and Wanfang databases were searched from inception to December 2020. Included were clinical studies that described the efficacy and safety of 2 of the 3 treatments, studies directly comparing the clinical effects of the 2 operative techniques, or studies comparing the effects of reconstruction or repair with nonoperative treatment. Two reviewers independently extracted data and assessed the quality of the included studies with the Cochrane risk-of-bias tools. The outcomes evaluated were postoperative redislocation rate, revision rate, complications, and Kujala score. We used traditional direct pairwise meta-analysis as well as network meta-analysis for comprehensive efficacy of all 3 treatment measures.
RESULTS
Twelve studies were included: 5 compared MPFL reconstruction with MPFL repair, 2 compared MPFL reconstruction with nonoperative treatment, and 5 compared MPFL repair with nonoperative treatment. The risk of bias was serious in 4, moderate in 4 and low in 4 articles. MPFL reconstruction led to significantly reduced redislocation and improved Kujala scores compared with MPFL repair and nonoperative treatment. MPFL repair led to reduced redislocation rates compared with nonoperative treatment but did not show an obvious benefit in primary dislocations. There was no significant difference among the 3 treatments in terms of revision rate and incidence of complications, although we found that treatment-related complications were least likely to occur in nonoperative treatment.
CONCLUSION
The results of this review indicate that MPFL reconstruction decreases recurrent dislocation compared with MPFL repair or nonoperative treatment, but it has a higher possibility of complications. MPFL repair resulted in less postoperative redislocation than nonoperative treatment but did not show an obvious benefit in primary dislocation.
PubMed: 34604425
DOI: 10.1177/23259671211026624 -
Knee Surgery, Sports Traumatology,... Oct 2014While there are numerous anatomic contributors to patellar instability, the role of patella alta has been traditionally under-appreciated. The goal of this systematic... (Review)
Review
PURPOSE
While there are numerous anatomic contributors to patellar instability, the role of patella alta has been traditionally under-appreciated. The goal of this systematic review is to identify the described techniques for treating patella alta in skeletally mature patients with episodic patellar dislocation (EPD) and review their published results.
METHODS
A comprehensive literature review was performed to identify published surgical techniques and their results. Tibial tubercle distalization is the primary described treatment for patellar alta in patients with EPD, and five studies reporting results of this procedure were reviewed.
RESULTS
Tibial tubercle distalization was generally successful in normalizing patellar height and preventing recurrent patellar dislocation. Physical examination tests for instability such as patellar apprehension remained positive in 15 to 33% of patients. Patient-reported outcomes were rarely reported and difficult to interpret given the lack of pre-operative values or comparison groups.
CONCLUSION
Tibial tubercle distalization is an effective technique for correction of patellar height and preventing recurrent patellar dislocations. More comparative studies are required to evaluate patient-reported outcomes of this technique, the effect of an associated tubercle medialization, and the results of supplementing distalization with procedures such as MPFL reconstruction.
LEVEL OF EVIDENCE
Systematic review of case series, Level IV.
Topics: Humans; Joint Instability; Knee Joint; Patella; Patellar Dislocation; Tibia; Treatment Outcome
PubMed: 23392290
DOI: 10.1007/s00167-013-2445-8 -
Arthroscopy : the Journal of... Aug 2017To perform a systematic review of literature reporting on outcomes after surgical treatment of medial patellar instability. (Review)
Review
PURPOSE
To perform a systematic review of literature reporting on outcomes after surgical treatment of medial patellar instability.
METHODS
A systematic review was performed according to PRISMA guidelines. Inclusion criteria were as follows: the outcomes and complications of medial patellar instability repair with a follow-up greater than 12 months, English language, and human studies. We excluded cadaveric studies, animal studies, basic science articles, editorial articles, review articles, and surveys.
RESULTS
Searches identified 1,116 individual titles. After inclusion and exclusion criteria were applied, a total of 8 studies were identified. Three studies exclusively included patients with previous lateral release; 1 included patients with chronic instability; 1 included patients with both previous lateral release and other surgical causes; 1 study had patients with previous lateral release, spontaneous instability, and instability due to injury; 1 study included patients after tibial tubercle transfer surgery; and 1 study did not report the etiology of instability.
CONCLUSIONS
Good to excellent outcomes were reported postoperatively in 85% of the patients after surgical treatment of medial patellar instability. However, clinical outcomes data for medial patellar ligament reconstruction is sparse and highly heterogeneous. There is inconsistency in the literature in regard to the indication, timing, and procedure.
LEVEL OF EVIDENCE
Level IV, systematic review of Level IV studies.
Topics: Arthroscopy; Humans; Joint Instability; Knee Joint; Patellar Dislocation; Practice Guidelines as Topic; Plastic Surgery Procedures; Treatment Outcome
PubMed: 28501222
DOI: 10.1016/j.arthro.2017.03.012 -
Knee Surgery, Sports Traumatology,... Jul 2023This study aimed to explore the efficacy of medial patellofemoral ligament (MPFL) repair versus nonoperative rehabilitation treatment on the rate of patellar... (Meta-Analysis)
Meta-Analysis Review
MPFL repair after acute first-time patellar dislocation results in lower redislocation rates and less knee pain compared to rehabilitation: a systematic review and meta-analysis.
PURPOSE
This study aimed to explore the efficacy of medial patellofemoral ligament (MPFL) repair versus nonoperative rehabilitation treatment on the rate of patellar redislocation and functional outcomes in skeletally mature patients with traumatic, first-time patellar dislocations.
MATERIALS AND METHODS
MEDLINE, PubMed and EMBASE were searched from database inception to May 2022 for studies examining the management options for acute first-time patellar dislocations. This study was conducted in accordance with PRISMA and R-AMSTAR guidelines. Data on redislocation rates, functional outcomes including the Kujala score for anterior knee pain, and complication rates were extracted. A meta-analysis was used to pool the mean postoperative Kujala score and calculate the proportion of patients sustaining redislocations using a random effects model. Quality assessment of included studies was performed for all included studies using the MINORS and Detsky scores.
RESULTS
This review included a total of 25 studies and 1,361 patients. The pooled mean redislocation rate in 15 studies comprising 798 patients in the rehabilitation group was 30% (95% CI 25-36%, I = 65%). Moreover, the pooled mean redislocation rate in 10 studies comprising 170 patients undergoing MPFL repair was 7% (95% CI 3-12%, I = 30%). The pooled mean postoperative Kujala score in 8 studies comprising 396 patients in the rehabilitation group was 82.5 (95% CI 78.3-86.8, I = 91%), compared to a score of 88 (95% CI 87-90, I = 76%) in 3 studies comprising 94 patients in the repair group. Range of motion deficits was reported in 3.8% of 893 patients in the rehabilitation group and 2.0% of 205 patients in the repair group.
CONCLUSION
MPFL repair resulted in a lower rate of redislocation, less knee pain, and noninferiority with respect to a range of motion deficits compared to nonoperative treatment for the management of acute first-time patellar dislocations.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Patellar Dislocation; Patellofemoral Joint; Knee Joint; Knee; Ligaments, Articular; Joint Dislocations; Pain; Joint Instability
PubMed: 36372845
DOI: 10.1007/s00167-022-07222-w -
Arthroscopy : the Journal of... May 2016To evaluate clinical outcomes, rate of recurrence, and complications following distal realignment procedures (Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and... (Review)
Review
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.
Topics: Arthrodesis; Humans; Joint Instability; Knee Joint; Osteotomy; Patellar Dislocation; Recurrence; Tibia
PubMed: 26921127
DOI: 10.1016/j.arthro.2015.10.019 -
Journal of Orthopaedics 2020Patellar dislocations are a significant injury with the potential for long term problems. Little work has been done on establishing the mechanism by which this injury... (Review)
Review
BACKGROUND
Patellar dislocations are a significant injury with the potential for long term problems. Little work has been done on establishing the mechanism by which this injury occurs.
OBJECTIVES
To determine the mechanism of injury of a patella dislocation based on the available published literature and compare them to already proposed theories.
METHODS
A systematic review of the literature was conducted following searches performed on MEDLINE, EMBASE and ProQuest from the earliest year of indexing using the following search terms in any combination: "patella", "dislocation", "mechanism of injury", "anatomy", "biomechanical" and "risk factor". A broad inclusion criteria was used that included studies that looked at patellar dislocations and instability with respect to the patellofemoral joint (PFJ) kinematics or altered kinematics of the PFJ. Studies that did not address the kinematics or biomechanics of the PFJ were excluded. Studies were appraised based on their methodology using a combination of the Critical Appraisal Skills Programme tool and the Quality Appraisal for Cadaveric Studies.
RESULTS
113 studies were identified from a search of MEDLINE, EMBASE and ProQuest databases. Following application of our inclusion criteria, a total of 23 studies were included in our review. 18 of these studies were cadaveric biomechanical studies. The remaining studies were anatomical, imaging based, and a computer simulation based study.
CONCLUSIONS
These biomechanical and kinematic studies provide some evidence that a dislocation is likely to occur during early knee flexion with external rotation of the tibia and contraction of the quadriceps. There is limited evidence to support other elements of proposed mechanisms of dislocation.
PubMed: 32042233
DOI: 10.1016/j.jor.2019.11.018 -
Arthroscopy : the Journal of... Nov 2018To clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the techniques yields better improvement in... (Meta-Analysis)
Meta-Analysis
PURPOSE
To clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the techniques yields better improvement in stability and functional recovery for patellar dislocation.
METHODS
The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus electronic databases were searched for relevant articles comparing the outcomes of medial patellofemoral ligament (MPFL) treatment published up until August 2017. Data searching, extraction, analysis, and quality assessment were performed based on The Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome values in various techniques. For results with high heterogeneity, 95% prediction intervals (PIs) were also investigated.
RESULTS
Eleven clinical studies were investigated. In patients with primary patellar dislocation, there were no significant differences in all evaluated outcomes between the conservative and surgical treatment groups. For patients with recurrent patellar dislocation, MPFL reconstruction was associated with a favorable Kujala score (mean difference, -8.91; 95% confidence interval, -14.05 to -3.77; I = 94%; 95% PI, -9.64 to -8.1) and Lysholm score (mean difference, -13.51; 95% confidence interval, -21.35 to -5.68; I = 96%; 95% PI, -14.86 to -12.16) when compared with soft tissue realignment surgery.
CONCLUSIONS
Although surgical treatment of the MPFL for primary patellar dislocation is not superior to conservative treatment in restoring knee function and clinical outcomes, MPFL reconstruction is associated with more favorable clinical outcomes compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. Double-bundle MPFL reconstruction seems to provide more favorable outcomes than single-bundle MPFL reconstruction, but this finding should be interpreted with caution because the evidence levels were low and were from only a few studies.
LEVEL OF EVIDENCE
Level III, meta-analysis.
Topics: Conservative Treatment; Humans; Ligaments, Articular; Orthopedic Procedures; Patellar Dislocation; Patellofemoral Joint; Recovery of Function
PubMed: 30301628
DOI: 10.1016/j.arthro.2018.06.052 -
Arthroscopy : the Journal of... Mar 2016To compare the clinical outcomes between medial soft-tissue surgery and medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation without... (Review)
Review
PURPOSE
To compare the clinical outcomes between medial soft-tissue surgery and medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation without any evident predisposing factors.
METHODS
A literature search was performed on the established medical databases MEDLINE, EMBASE, and the Cochrane register. The inclusion criteria were as follows: English-language papers for recurrent patellar dislocation without any evident predisposing factors, clinical trial(s) with clear description of surgical technique, adult subjects, medial soft-tissue surgery or MPFL reconstruction without combined surgery, and a follow-up longer than 2 years. The methodological quality of all articles was assessed by 2 authors according to the Coleman methodology score.
RESULTS
Thirteen studies (mean Coleman methodology score value, 74.1; standard deviation, 11.5) were included in the analysis. Five studies reported the outcomes of patients undergoing medial soft-tissue surgery, compared with 7 studies reporting MPFL reconstruction. Overall, 109 patients underwent medial soft-tissue surgery with a minimum 2-years follow-up, compared with 308 patients of MPFL reconstruction. There was one direct comparative study between medial soft-tissue surgery and MPFL reconstruction. Of the patients who received medial soft-tissue surgery, 0 to 9.7% experienced redislocation, compared with 0 to 10.7% of the MPFL reconstruction group. The ranges of differences in Kujala scores were 23.6 to 31.7 points in patients who underwent medial soft-tissue surgery and 23.11 to 38.8 points in patients who underwent MPFL reconstruction. The ranges of postoperative congruence angles were -14.4° to 8.2° for medial soft-tissue surgery and -7.7° to -5.2° for MPFL reconstruction. The ranges of postoperative lateral patellofemoral angles were 7.9° to 9.4° for medial soft-tissue surgery and 5° to 5.3° for MPFL reconstruction.
CONCLUSIONS
All studies on medial soft-tissue surgery and MPFL reconstruction for recurrent patellar dislocation without predisposing factors showed satisfactory outcomes despite the use of numerous surgical techniques, graft types, and follow-up periods.
LEVEL OF EVIDENCE
Level IV, Systematic Review.
Topics: Humans; Ligaments, Articular; Orthopedic Procedures; Patellar Dislocation; Plastic Surgery Procedures; Recurrence
PubMed: 26545305
DOI: 10.1016/j.arthro.2015.08.012 -
Knee Surgery, Sports Traumatology,... Oct 2014Medial structures repair is a well-established approach in the treatment for patellar instability. However, the literature is confusing concerning the indications for... (Review)
Review
PURPOSE
Medial structures repair is a well-established approach in the treatment for patellar instability. However, the literature is confusing concerning the indications for surgery, the different surgical techniques and outcomes. The goal of this systematic review was to clarify the indications for medial structures repair and to analyse the results of both arthroscopic and open techniques.
METHODS
A comprehensive literature review was performed using the keywords 'patellar instability', 'medial capsule reefing' and 'medial capsule plication' with no limit regarding the year of publication. All the selected articles in Anglo-Saxon language were evaluated with the Coleman methodology score.
RESULTS
Seventeen full-text articles were evaluated. Initial cohort included 617 patients. About 569 patients were reviewed at an average FU of 54.6 months (range 2-165 months) after medial structures repair. Average age at the time of surgery was 21.2 years (range 9-65 years). The indications for surgery included both patellar subluxation and dislocation (acute or chronic). Average Kujala score increased from 55 to 84 at the last FU, and in the same way average Lysholm score increased from 41.2 to 80.5, whereas average Tegner score increased from 3 to 5.3 and IKDC score from 47.8 to 75.1. Re-dislocation rate among the series was 6.1%. Average Coleman methodology score was 61.6 (range 17-92).
CONCLUSION
From this review, it emerges that medial capsule reefing is a reliable option in the treatment for patellar instability. It can be proposed with good expectations, since the outcomes are positive and stable even at longer FU and complications rates are low. Re-dislocation rate is variable and can occur in up to one-third of patients. However, most of the available studies are case series, and comparison of the series is hard since they widely differ in inclusion criteria and indications, surgical technique and additional procedures, and outcome measures.
Topics: Arthroplasty; Arthroscopy; Humans; Joint Instability; Knee Joint; Patellar Dislocation
PubMed: 25059335
DOI: 10.1007/s00167-014-3171-6