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Orthopaedic Journal of Sports Medicine Sep 2020Whether surgical or nonsurgical management is more appropriate for primary patellar dislocations (PPDs) in adolescents (younger than 18 years) remains controversial. (Review)
Review
BACKGROUND
Whether surgical or nonsurgical management is more appropriate for primary patellar dislocations (PPDs) in adolescents (younger than 18 years) remains controversial.
PURPOSE
To compare the clinical outcomes of surgical versus nonsurgical treatment for adolescents and children with PPDs.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
There were 2 reviewers who independently searched the PubMed, Embase, Ovid, and Cochrane databases for English-language studies of randomized controlled trials (RCTs), quasi-RCTs, and observational studies comparing surgical with nonsurgical treatment for PPDs. The primary outcomes were redislocations, the Kujala score, and the Knee injury and Osteoarthritis Outcome Score (KOOS), and the secondary outcome was subsequent surgery.
RESULTS
A total of 6 studies were included in our systematic review and meta-analysis. Among patients younger than 18 years, surgery was associated with a lower redislocation rate compared with nonsurgical treatment within 5 years of treatment (risk ratio [RR], 0.58 [95% CI, 0.37-0.91]; = .02; = 47%) but not beyond 5 years (RR, 0.80 [95% CI, 0.59-1.07]; = .14; = 34%). However, surgery resulted in worse Kujala and KOOS scores compared with nonsurgical treatment. Yet, the treatment difference between the 2 groups tended to decrease over time.
CONCLUSION
The available evidence suggests that for adolescents with PPDs, surgery was superior to nonsurgical treatment in the short term to reduce the redislocation rate but resulted in poorer outcomes of knee function based on the Kujala and KOOS scores. However, the superiority of either surgical or nonsurgical treatment in adolescents did not appear to persist in the long term.
PubMed: 33015209
DOI: 10.1177/2325967120946446 -
Indian Journal of Orthopaedics Feb 2023The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing...
PURPOSE
The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing for patients with first-time patellar dislocation.
METHODS
Databases of PubMed, EMBASE, Cochrane Library and Web of Science were searched up to May 8, 2022. Only articles treating first-time patellar dislocation with MPFL reconstruction, MPFL repair and medial reefing were included in the analysis. Eligible identification, data extraction, quality assessment and statistical analysis were performed by two independent reviewers. The primary outcome measures were the incidences of postoperatively redislocation and reoperation. The second outcomes were the Kujala functional score and complications (including infection, osteoarthritis, and loss of range of motion).
RESULTS
Twenty-two studies involving 668 patients met the inclusion criteria. Of which, four studies involving 126 patients were in MPFL reconstruction group, ten studies involving 220 patients in MPFL repair group and 9 studies involving 322 patients in medial reefing group. Our results showed that the MPFL reconstruction (1.8%, 95% CI - 0.5 to 4.0%) had a significantly lower rate of postoperative redislocation and reoperation rate than the MPFL repair (15.4%, 95% CI 5.2-25.7%) and medial reefing (18.0%, 95% CI 9.3-26.7%). Besides, no significant differences were found in the Kujala score and complication rate among the three treatments.
CONCLUSION
The available evidence demonstrated that MPFL reconstruction could achieve significantly lower redislocation rate and reoperation rate than MPFL repair and medial reefing after first-time patella dislocation. Furthermore, there was not enough evidence to reveal that MPFL reconstruction provided better functional outcome compared with MPFL repair and medial reefing. MPFL reconstruction is a preferred surgical treatment for patients with first-time patellar dislocation.
LEVEL OF EVIDENCE
Level IV, systematic review of Level I-IV.
PubMed: 36777132
DOI: 10.1007/s43465-022-00770-w -
Orthopaedic Journal of Sports Medicine Jul 2023An increased femoral anteversion angle (FAA) is a predisposing factor for recurrent patellar dislocations (RPDs), and combined procedures including derotational distal... (Review)
Review
BACKGROUND
An increased femoral anteversion angle (FAA) is a predisposing factor for recurrent patellar dislocations (RPDs), and combined procedures including derotational distal femoral osteotomy (DDFO) have been shown to be good options.
PURPOSE
To investigate the safety and effectiveness of combined DDFO on clinical and radiological outcomes to treat RPDs with an increased FAA.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. We searched 7 databases for articles from inception to March 10, 2023, that reported outcomes after combined DDFO in patients with an RPD and increased FAA. Two reviewers independently extracted data and assessed study quality. Outcomes evaluated were functional scores, redislocation rates, complications, satisfaction, and radiological parameters. A meta-analysis was performed to pool functional scores, with data reported as mean differences (MDs) and 95% confidence intervals (CIs).
RESULTS
Included were 8 studies of 189 knees from 183 patients, with a mean patient age of 22.4 years and a mean follow-up of 33.4 months. The mean preoperative FAA ranged from 31° to 42.70°, and the mean postoperative FAA ranged from 10° to 19.08°. Significant improvements were found in the Kujala score (MD, 26.96 [95% CI, 23.54 to 30.37]), Lysholm score (MD, 26.17 [95% CI, 22.13 to 30.22]), visual analog scale score for pain (MD, -2.61 [95% CI, -3.12 to -2.10]), and Tegner activity score (MD, 1.33 [95% CI, 0.86 to 1.79]). No subluxation or redislocation occurred. The overall complication rate was 10.6%, and most of the complications were pain (60%) and limited knee activity (20%). The overall satisfaction rate was 83.3%. The patellar tilt angle significantly decreased from 40.7° ± 11.9° to 20.5° ± 8.7° and from 26.35° ± 6.86° to 11.65° ± 2.85° in 2 studies.
CONCLUSION
Combined DDFO was found to be safe and effective for the treatment of RPDs and an increased FAA by addressing both patellar dislocations and torsional malalignment. However, because of the lack of comparisons, it remains to be investigated when DDFO should be combined in such patients.
PubMed: 37465210
DOI: 10.1177/23259671231181601 -
Journal of Orthopaedic Surgery and... Nov 2020The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart...
BACKGROUND
The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart stability to the patellofemoral joint. The anatomy and biomechanical characteristics of the MPFL have been well described but little is known about the MPTL and MPML. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, patellar and quadriceps tendons, allografts and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident.
METHODS
A systematic review of the literature was conducted using PRISMA guidelines. Inclusion criteria were articles that reported clinical outcomes of combined reconstruction of MPTL and MPFL. The methodological quality of the articles was determined using the modified Coleman Methodology Score (CMS).
RESULTS
Nine articles were included, reporting the clinical outcomes of 197 operated knees. The surgical procedures described include hamstrings grafting and transfer of the medial patellar and quadriceps tendons with or without bony procedures to reconstruct the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved. The median CMS is 70.6 ± 14.4 (range 38 to 84).
CONCLUSION
Different techniques are reported, and outcomes are good with low rates of recurrence. The quality of the articles is variable, ranging from low to high. Appropriately powered randomized controlled trials are needed to better understand what the adequate indications for surgery in patients with patellar instability and clinical outcomes are. Combined reconstruction of MPFL and MPTL leads to favourable clinical outcomes, supporting its role as a valid surgical procedure for patellar stabilization.
Topics: Female; Humans; Joint Instability; Ligaments, Articular; Male; Orthopedic Procedures; Patella; Patellar Dislocation; Patellofemoral Joint; Plastic Surgery Procedures; Tibia; Treatment Outcome
PubMed: 33183310
DOI: 10.1186/s13018-020-02072-z -
Orthopaedic Journal of Sports Medicine Apr 2021Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists... (Review)
Review
BACKGROUND
Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition.
PURPOSE
To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators.
RESULTS
A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48).
CONCLUSION
Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.
PubMed: 33997063
DOI: 10.1177/2325967121999642 -
Orthopaedic Journal of Sports Medicine Dec 2020Medial patellofemoral ligament (MPFL) injuries are common in patients with acute lateral patellar dislocations, but the pattern of MPFL injuries is unclear, especially... (Review)
Review
BACKGROUND
Medial patellofemoral ligament (MPFL) injuries are common in patients with acute lateral patellar dislocations, but the pattern of MPFL injuries is unclear, especially with respect to patient age.
PURPOSE
The primary aim was to determine the prevalence of MPFL injuries according to the site of injury in patients with acute lateral patellar dislocations. The secondary aim was to compare the site of MPFL injuries in patients aged ≤16 versus >16 years.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A systematic literature search was performed with PubMed, Embase, and CINAHL to identify articles published from January 1, 1999, to May 31, 2019, that examined the site of MPFL injuries in patients with acute patellar dislocations. The study design, sample size, age at injury, technique used for diagnosing MPFL injuries (magnetic resonance imaging, ultrasound, and/or surgery), and prevalence and site of MPFL injuries were extracted from each study. The pooled estimate of the proportion of MPFL injuries at each site was calculated (femur, patella, midsubstance, and combined sites of injury) as well as proportions stratified by age group (≤16 and >16 years).
RESULTS
The literature search yielded 420 unique articles, of which 52 were screened for eligibility; of these, 17 were excluded. Thus, a total of 35 articles (2558 patients) were included in the final analysis. The overall prevalence of MPFL injuries was 94.7% (95% CI, 91.2%-96.8%). Most MPFL injuries occurred at the patella (37.1% [95% CI, 30.8%-43.9%]), followed by the femur (36.8% [95% CI, 31.0%-43.0%]), combined sites (25.1% [95% CI, 20.7%-30.1%]), and the midsubstance (15.6% [95% CI, 13.2%-18.4%]). In patients aged ≤16 years, most MPFL injuries occurred at the patella (39.3% [95% CI, 27.9%-51.9%]), and in patients aged >16 years, most MPFL injuries occurred at the femur (47.2% [95% CI, 40.6%-54.0%]).
CONCLUSION
The prevalence of MPFL injuries in patients with acute patellar dislocations varied by site of injury and by age. MPFL injuries at the patella were most prevalent overall and in children and adolescents, and MPFL injuries at the femur were more prevalent in adults.
PubMed: 33403210
DOI: 10.1177/2325967120967338 -
Arthroscopy : the Journal of... Aug 2014This study aimed to determine the ability of patients to return to activity after medial patellofemoral ligament (MPFL) reconstruction or repair for patellar instability. (Review)
Review
PURPOSE
This study aimed to determine the ability of patients to return to activity after medial patellofemoral ligament (MPFL) reconstruction or repair for patellar instability.
METHODS
A systematic review was performed using multiple databases. Studies reporting outcomes with Tegner scores after repair or reconstruction of the MPFL were included. Surgical technique, Tegner scores, and episodes of recurrent patellar instability were recorded.
RESULTS
Ten articles with a total of 402 patients were included. The mean preoperative Tegner score was 4.7 (2.9 to 7.5). The mean postoperative Tegner score was 5.8 (4.0 to 7.7). Forty-nine patients (12.2%) had a recurrent episode of instability, 11 of whom required additional corrective procedures. There was a statistically significant larger failure rate among those who underwent MPFL repair (26.9%) than those who underwent reconstruction (6.6%) or medial retinacular repair/plication (16.5%).
CONCLUSIONS
Recurrent dislocation was higher in patients who underwent MPFL repair rather than reconstruction. However, repair and reconstruction had similar Tegner scores. Repair or reconstruction of the soft tissue structures contributing to patellofemoral instability is successful in returning patients to preinjury activity levels.
LEVEL OF EVIDENCE
Level IV, systematic review of Level II, III, and IV studies.
Topics: Humans; Joint Instability; Ligaments, Articular; Patellofemoral Joint; Plastic Surgery Procedures; Recovery of Function; Return to Work
PubMed: 24768468
DOI: 10.1016/j.arthro.2014.02.044 -
Knee Surgery, Sports Traumatology,... Jan 2024The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and... (Meta-Analysis)
Meta-Analysis Review
Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta-analysis.
PURPOSE
The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and medial patellofemoral ligament reconstruction (MPFL-R) in the treatment of recurrent patellar dislocation (RPD) with increased femoral anteversion angle (FAA).
METHODS
This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality Of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science and Cochrane Library databases were searched to identify studies reporting clinical outcomes of combined D-DFO and MPFL-R in RPD patients with increased FAA. Data on patient-reported outcome measures, radiological parameters, patellar tracking as revealed by J-sign and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis.
RESULTS
Eleven studies with a total of 569 knees in 553 patients were included. Patients were predominantly female (79%). The weighted mean of FAA decreased from 33.6° to 13.0° (weighted mean difference = 20.59; p < 0.00001) after the combined procedure. Significant improvements (p < 0.00001) were identified in the Lysholm score (weighted mean: 55.5 vs. 80.4), International Knee Documentation Committee (IKDC) score (weighted mean: 52.8 vs. 78.6) and Kujala score (weighted mean: 54.5 vs. 80.6). The incidence of residual J-sign ranged from 14.3% to 38.3% with an overall pooled rate of 28.2% (95% confidence interval = 22.8%-33.6%). The overall redislocation rate was 1.1%. No patients experienced surgical site infection or bone nonunion. Two studies compared the clinical outcomes of MPFL-R with and without D-DFO. Compared with isolated MPFL-R, the combined procedure yielded a better Lysholm score (weighted mean: 84.9 vs. 79.3, p < 0.0001), IKDC score (weighted mean: 84.1 vs. 79.9, p = 0.001), Kujala score (weighted mean: 84.3 vs. 79.4, p < 0.0001) and a lower residual J-sign rate (26/97 [26.8%] vs. 44/105 [41.9%], p = 0.02), respectively.
CONCLUSION
The combination of D-DFO and MPFL-R led to improved clinical outcomes and a low redislocation rate in patients with RPD and increased FAA. Additional D-DFO can achieve more favourable results in subjective function and patellar tracking than isolated MPFL-R in the setting of excessive FAA.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Female; Male; Patellar Dislocation; Patellofemoral Joint; Femur; Joint Dislocations; Osteotomy; Ligaments, Articular; Joint Instability; Patellar Ligament
PubMed: 38226710
DOI: 10.1002/ksa.12021 -
Knee Surgery, Sports Traumatology,... Jun 2023To determine the effect of isolated medial patellofemoral ligament reconstruction (MPFLR) versus concomitant MPFLR and tibial-tubercle osteotomy (TTO) on... (Meta-Analysis)
Meta-Analysis Review
Isolated medial patellofemoral ligament reconstruction results in similar postoperative outcomes as medial patellofemoral ligament reconstruction and tibial-tubercle osteotomy: a systematic review and meta-analysis.
PURPOSE
To determine the effect of isolated medial patellofemoral ligament reconstruction (MPFLR) versus concomitant MPFLR and tibial-tubercle osteotomy (TTO) on patient-reported functional outcomes, rate of patellar redislocation, and rate of return to sport in skeletally mature patients with recurrent patellar instability and lateralization as defined by elevated tibial-tubercle trochlear groove (TT-TG) distance.
METHODS
Three databases MEDLINE, PubMed and EMBASE were searched from inception to July 10th, 2022 for literature outlining the management of patients with TT-TG indices greater than 15 mm with either isolated MPFLR or concomitant MPFLR and TTO procedures. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on functional outcomes via the Kujala anterior knee pain score, redislocation rates, return to sport rates, and complications were recorded. The MINORS score was used for all studies to perform a quality assessment of included studies.
RESULTS
A total of 31 studies comprising 1405 patients (1452 knees) were included in this review. The mean Kujala score in 13 studies comprising 848 total patients in the isolated MPFLR group was 85.0 (range 80.9-97.5) compared to a score of 83.7 (range 77.2-94.0) in 14 studies comprising 459 patients in the concomitant group. The mean pooled redislocation rate in 19 studies examining isolated MPFLR procedures comprising 948 patients was 3.1% (95% CI 2.1-4.4%, I = 7%) as opposed to 3.2% (95% CI 1.9-5.0%, I = 0%) in 15 studies comprising 486 patients in the concomitant group. The mean pooled return to sport rate in seven studies with 472 total patients in the isolated MPFLR group was 82% (95% CI 78-86%, I = 16%) compared to a score of 92% (95% CI 78-99%, I = 58%) in four studies comprising 54 patients in the concomitant group. There were similar complication rates between both treatment groups, including range of motion deficits, fractures, infections, and graft failures.
CONCLUSION
Isolated MPFLR leads to similar anterior knee pain, similar redislocation rates and lower return to sport rates than concomitant MPFLR and TTO procedures in patients with TT-TG distances greater than 15 mm. Information from this review can aid surgeons in their decision to choose MPFLR versus concomitant procedures for this patient population, and can also guide future studies on this topic.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Patellar Dislocation; Patellofemoral Joint; Joint Instability; Recurrence; Ligaments, Articular; Osteotomy; Pain
PubMed: 36214831
DOI: 10.1007/s00167-022-07186-x -
The American Journal of Sports Medicine Nov 2016A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is decreasing, and surgical intervention is more commonly recommended for those patients who fail initial nonoperative management with recurrent patellar dislocations. Medial patellofemoral ligament (MPFL) reconstruction has become increasingly utilized in this regard.
PURPOSE
To evaluate outcomes, particularly return to sports and its relationship to postoperative instability, of isolated MPFL reconstruction for the treatment of recurrent patellar dislocations.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
A review of the current literature was performed using the terms "medial patellofemoral ligament reconstruction" and "MPFL reconstruction" in the electronic search engines PubMed and EBSCOhost (CINAHL, MEDLINE, SPORTDiscus) on July 29, 2015, yielding 1113 abstracts for review. At the conclusion of the search, 14 articles met the inclusion criteria and were included in this review of the literature. Means were calculated for population size, age, follow-up time, and postoperative Tegner scores. Pooled estimates were calculated for postoperative Kujala scores, return to play, total risk of postoperative instability, risk of positive apprehension sign, and risk of reoperation.
RESULTS
The mean patient age associated with MPFL reconstruction was 24.4 years, with a mean postoperative Tegner score of 5.7. The pooled estimated mean postoperative Kujala score was 85.8 (95% CI, 81.6-90.0), with 84.1% (95% CI, 71.1%-97.1%) of patients returning to sports after surgery. The pooled total risk of recurrent instability after surgery was 1.2% (95% CI, 0.3%-2.1%), with a positive apprehension sign risk of 3.6% (95% CI, 0%-7.2%) and a reoperation risk of 3.1% (95% CI, 1.1%-5.0%).
CONCLUSION
A high percentage of young patients return to sports after isolated MPFL reconstruction for chronic patellar instability, with short-term results demonstrating a low incidence of recurrent instability, postoperative apprehension, and reoperations.
Topics: Humans; Incidence; Joint Instability; Patellar Dislocation; Patellar Ligament; Postoperative Period; Recurrence; Return to Sport; Treatment Outcome
PubMed: 26872895
DOI: 10.1177/0363546515624673