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Journal of Orthopaedic Surgery and... Aug 2021Open reduction internal fixation (ORIF) has long been the conventional procedure for managing displaced patella fracture. This surgical approach has certain drawbacks,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Open reduction internal fixation (ORIF) has long been the conventional procedure for managing displaced patella fracture. This surgical approach has certain drawbacks, which might affect clinical outcomes and patient prognosis. Minimally invasive percutaneous fixation (MIPF) was proposed to overcome these disadvantages. Few in-depth investigations have been performed to determine the superiority of MIPF over ORIF. The aim of this study was to compare the efficacies of MIPF and ORIF for patella fractures.
METHODS
The PubMed, Cochrane Library, Embase, and Scopus databases were searched for relevant studies from November 26 to December 17, 2020. Non-English publications and pediatric orthopedic articles were excluded. Statistical analysis was performed using Review Manager, version 5.4, with mean differences (MDs), standardized mean differences (SMDs), odds ratios (ORs), and respective 95% confidence intervals (CIs) calculated using a random effects model. The primary outcomes were the pain score, knee range of motion, and joint functionality. The secondary outcomes were the surgical time, complications, and implant removal rate.
RESULTS
Six articles with a total of 304 patients were included in the meta-analysis. Pooled analysis revealed that patients with MIPF had a significantly reduced pain score (MD = - 1.30, 95% CI = - 1.77 to -0.82; p < 0.00001) and increased knee extension angles (MD = 0.72, 95% CI = 0.18 to 1.25; p = 0.009) at 3-month follow-up. Furthermore, knee flexion angles (MD = 8.96, 95% CI = 5.81 to 12.1; p < 0.00001) and joint functionality (SMD = 0.54, 95% CI = 0.21 to 0.86; p = 0.001) had statistically improved at 2 years. However, no difference was observed between MIPF and ORIF with regard to the surgical time. The risk of complications (OR = 0.10, 95% CI = 0.05 to 0.18; p < 0.00001) and implant removal rate (OR = 0.20, 95% CI = 0.07 to 0.57; p = 0.003) were significantly lower with MIPF than with ORIF.
CONCLUSIONS
MIPF is more favorable than ORIF in terms of the pain score, knee range of motion, joint functionality, complications, and implant removal rate. Thus, it can be adopted as an alternative to ORIF.
Topics: Child; Fracture Fixation, Internal; Fractures, Bone; Humans; Knee Injuries; Open Fracture Reduction; Pain; Patella; Treatment Outcome
PubMed: 34404423
DOI: 10.1186/s13018-021-02612-1 -
International Orthopaedics Dec 2021The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of partial patellectomy (PP) in patients with patella comminuted distal pole...
PURPOSE
The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of partial patellectomy (PP) in patients with patella comminuted distal pole fractures.
METHODS
Seventeen patients who were diagnosed with patella comminuted distal pole fractures and underwent PP procedures were retrospectively included between January 1995 and January 2005. We collected patient demographics and data on the mechanism of injury, time to surgery, fracture type, follow-up time, and post-operative complications (infection, patellofemoral arthritis, and stiffness). At the final follow-up, functional outcome was evaluated by the range of motion (ROM) and the Bostman Scoring System. Quadriceps strength was evaluated by using an isokinetic dynamometer to measure peak torque, and patellar height was evaluated by the Insall-Salvati (IS) ratio in lateral knee radiographs. The average follow-up period was 14.6 years (range, 11-19 years).
RESULTS
We analyzed 17 patients (AO/OTA 34-A1), with an average age of 59.8 years (range, 43-76 years). According to the Bostman grading scales, final functional outcomes were excellent in 11 (64.7%) and good in six (35.3%) patients. All patients had full knee extension, and the average ROM was 125.1° (range, 121.4-129.3°). The average peak torque of the injured knee was 103.2 ± 9.7 Nm, and that of the uninjured opposite side was 108.3 ± 7.6 Nm, with no significant difference (p > 0.05). Furthermore, no postoperative complications, such as infection, posttraumatic osteoarthritis, or stiffness, were observed. Compared to the uninjured knee, the IS ratio of the injured knee was 0.76 ± 0.13, indicating that the patellar height was decreased, which meant patella baja.
CONCLUSIONS
The PP procedure for patella comminuted distal pole fractures is a safe, simple, and reliable technique that can provide good long-term clinical outcomes even with decreased patellar height and could be a satisfactory alternative treatment option when anatomical reduction is difficult.
Topics: Fracture Fixation, Internal; Fractures, Bone; Fractures, Comminuted; Humans; Middle Aged; Patella; Range of Motion, Articular; Retrospective Studies; Treatment Outcome
PubMed: 34195867
DOI: 10.1007/s00264-021-05127-w -
Anatomical Record (Hoboken, N.J. : 2007) Oct 2017The patella is one of the most studied sesamoids. Historically, the patella is described as a big sesamoid embedded in the tendon of the quadriceps femoris muscle. This... (Comparative Study)
Comparative Study
The patella is one of the most studied sesamoids. Historically, the patella is described as a big sesamoid embedded in the tendon of the quadriceps femoris muscle. This sesamoid is studied from developmental, functional, clinical, and anatomical perspectives. The presence of a patella is reported in squamatans, birds, and mammals. Lissamphibians are identified as the major lineage that fail to develop a patella. However, this sesamoid is reported at least once in anurans, but without detailed anatomical discussions. Through anatomical and histological studies we examined the topography and tissue composition of two structures that we identify as the proximal and distal patellae in several anuran species. We explored the evolution of these sesamoids through ancestral state reconstruction, finding that they are ancestral for amphibians and possibly tetrapods as a whole. The presence of these patellae in anurans would roll back their origin to the last common ancestor of tetrapods. From a functional perspective, the overwhelming evidence of fibrocartilage as a clear response to compression suggests that the fibrocartilaginous patellae could also withstand the mechanical stress generated on the knee undergoing compression during limb extension. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:1747-1755, 2017. © 2017 Wiley Periodicals, Inc.
Topics: Animals; Anura; Biological Evolution; Patella
PubMed: 28667673
DOI: 10.1002/ar.23629 -
Journal of Orthopaedic Surgery and... Jan 2021The central ridge of the patella is the thickest area of patella and varies among patients. This cadaveric study identified the location and thickness of the bone at the...
INTRODUCTION
The central ridge of the patella is the thickest area of patella and varies among patients. This cadaveric study identified the location and thickness of the bone at the central patella ridge for bone-patellar tendon-bone (BPTB) harvesting.
MATERIALS AND METHODS
Fifty cadaveric knees were assessed. First, the morphology, length, width, and location of the central patellar ridge were recorded. Then, we transversely cut the patella 25 mm from the lower pole and measured the thickness of the anterior cortex, cancellous bone, and cartilage from both the mid-patella and the central ridge location. Finally, the depth of the remaining cancellous bone at the mid-patella was compared to the bone at the central ridge.
RESULTS
The location of the central-patellar ridge deviated medially from the mid-patella in 46 samples with an average distance of 4.36 ± 1 mm. Only 4 samples deviated laterally. The mean patella length was 41.19 ± 4.73 mm, and the width was 42.8 ± 5.25 mm. After a transverse cut, the remaining cancellous bone was significantly thicker at the central ridge compared to the bone at the mid-patella.
CONCLUSIONS
Most of the central patellar ridge deviated medially, approximately 4 mm from the mid-patella. Harvesting the graft from the central ridge would have more remaining bone compared to the mid-patella.
Topics: Anatomic Variation; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Bone-Patellar Tendon-Bone Grafts; Cadaver; Fractures, Bone; Humans; Patella; Plastic Surgery Procedures; Tissue and Organ Harvesting
PubMed: 33509240
DOI: 10.1186/s13018-021-02244-5 -
Knee Surgery, Sports Traumatology,... Jun 2015To conduct a systematic review and network meta-analysis of randomized controlled trials (RCTs) with the aim of comparing relevant clinical outcomes between patellar... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To conduct a systematic review and network meta-analysis of randomized controlled trials (RCTs) with the aim of comparing relevant clinical outcomes between patellar denervation, resurfacing and non-resurfacing.
METHODS
A database search was performed using PubMed and Scopus search engines. RCTs or quasi-experimental designs comparing clinical outcomes between treatments by a search of articles dated from inception to October 23, 2012. Unstandardized mean difference (UMD) and random effects methods were applied for pooling continuous and dichotomous outcomes, respectively. A longitudinal mixed regression model was used for network meta-analysis to indirectly compare treatment effects.
RESULTS
Eighteen of 315 studies identified were eligible. Compared with patellar non-resurfacing, patellar denervation had a UMD that displayed a significant improvement in symptoms with values in pain visual analog score (VAS) and Knee Society Score (KSS) of -0.6 [95% confidence interval (CI) -1.13, -0.25] and 2.55 (95% CI 0.43, 4.68), respectively. The UMD in VAS, KSS, and Knee Function Score (KFS) in patellar resurfacing showed no significant improvement in symptoms when compared to non-resurfacing. Patients who underwent surgery with patellar resurfacing had a lower reoperation rates with pooled relative risks (RRs) of 0.69 (95% CI 0.50, 0.94) when compared to non-resurfacing. The network meta-analysis suggested a benefit of borderline significance for patellar denervation with a pooled RR of 0.63 (95% CI 0.38, 1.03), showing that there is a lower chance of anterior knee pain when compared to non-resurfacing. Patellar resurfacing also displays a significantly lower chance of reoperation with a pooled RR of 0.68 (95% CI 0.50, 0.92) when compared to non-resurfacing. Multiple active treatment comparisons indicated that patellar denervation resulted in greater improvement in KFS than patellar resurfacing.
CONCLUSION
This review suggests that either patellar denervation or patellar resurfacing may be selected for the management of the patellofemoral component in total knee replacement. Patellar denervation may help improve postoperative knee function, but does not improve pain when compared to patellar resurfacing.
Topics: Arthroplasty, Replacement, Knee; Denervation; Humans; Knee Joint; Osteoarthritis, Knee; Patella; Postoperative Complications; Reoperation; Visual Analog Scale
PubMed: 25218579
DOI: 10.1007/s00167-014-3311-z -
The Journal of Bone and Joint Surgery.... Jul 2016The medial patellofemoral ligament varies in attachment of its fibers to the patella and vastus intermedius tendon. Our aim was to identify and describe its anatomic...
BACKGROUND
The medial patellofemoral ligament varies in attachment of its fibers to the patella and vastus intermedius tendon. Our aim was to identify and describe its anatomic midpoint. To account for the variability of the attachment site, we refer to it as the medial patellofemoral complex.
METHODS
Using AutoCAD software, we identified the midpoint of the medial patellofemoral complex attachment on photographs of 31 cadaveric knee dissections. The midpoint was referenced relative to the superior articular surface of the patella (P1) and was described in terms of the percentage of the patellar articular length distal to this point. A second point, at the junction of the medial border of the vastus intermedius tendon with the superior articular border of the patella, was identified (P2). The distances of the midpoint to P1 and P2 were calculated and were compared using paired t tests.
RESULTS
Twenty-five images had appropriate quality and landmarks for digital analysis. The midpoint of the medial patellofemoral complex was located a mean (and standard deviation) of 2.3% ± 15.8% of the patellar articular length distal to the superior pole and was at or proximal to P1 in 12 knees. In all knees, the midpoint was at or proximal to P2. After exclusion of 2 knees with vastus intermedius tendon attachments only, the medial patellofemoral complex midpoint was closer to P2 (5.3% ± 8.6% of the patellar articular length) than to P1 (9.3% ± 8.5% of the patellar articular length) (p = 0.06).
CONCLUSIONS
The midpoint of the medial patellofemoral complex was 2.3% of the articular length distal to the superior pole of the patella. Additionally, we describe an anatomic landmark at the junction of the medial border of the vastus intermedius tendon and the articular border of the patella that approximates the midpoint of this complex.
CLINICAL RELEVANCE
Our study shows that the anatomic midpoint of the attachment of the medial patellofemoral complex is proximal to the junction of the medial vastus intermedius tendon and the articular border of the patella, suggesting that graft placement may be more anatomic on the vastus intermedius tendon rather than on the patella.
Topics: Humans; Ligaments, Articular; Patella; Patellofemoral Joint; Software
PubMed: 27440568
DOI: 10.2106/JBJS.15.01182 -
The American Journal of Sports Medicine Mar 2022Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole...
BACKGROUND
Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larsen-Johansson syndrome (SLJS).
PURPOSE
The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF, and SLJS.
STUDY DESIGN
Cross-sectional study; Level of evidence, 3.
METHODS
Retrospective review of skeletally immature patients diagnosed with PSF, IPF, and SLJS between 2011 and 2019 at a single urban academic center was performed. Chart and radiographic review was completed. Between-group differences were assessed using analysis of variance, Kruskal-Wallis test, and Fisher exact test, as appropriate to variable distributions.
RESULTS
In total, 125 patients (82% male) were included, with a mean (SD) age of 10.7 (2) years (16 PSF, 51 IPF, 58 SLJS). There were no significant differences in patient characteristics between the 3 groups. One hundred percent of the patients with PSF ( < .001) and IPF ( < .001) had acute trauma, compared with 24% of patients with SLJS. Fewer patients with PSF had an intact straight leg raise (38%) compared with those with IPF (94%; < .001) and SLJS (98%; < .001). Fewer patients with SLJS had knee swelling (41%) compared with those with PSF (93%; < .001) and IPF (94%; < .001). More patients with PSF had knee effusion (81%) compared with those with IPF (37%; = 0.011) and SLJS (3%; < .001). More patients with SLJS were able to bear weight (88%) compared with those with IPF (12%; < .001) and PSF (0; < .001). Radiographically, compared with those with IPF and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 [ < .001] and 6.5 [ < .001] vs 12.9 mm), intra-articular effusion (6.1 [ = .014] and 4.9 [ = .001] vs 9.2 mm), maximum fragment size (26 [ = .004] and 17.7 [ < .001] vs 45.3 mm), and maximum fragment displacement (1.24 [ = .002] and 1.45 [ = .003] vs 13.30 mm), respectively. Compared with those with SLJS (1.10), patients with PSF (1.92; < .001) and IPF (1.22; < .001) had patella alta with higher mean Insall-Salvati ratios >1.2.
CONCLUSION
Differences in clinical features such as ability to straight leg raise, knee swelling, knee effusion, ability to bear weight, and radiographic features, such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location, and patellar height, can all be helpful in recognizing rare pediatric inferior patellar pathology, thus increasing efficiency in indicating for higher-level imaging to reach a prompt diagnosis and provide appropriate treatment.
Topics: Child; Cross-Sectional Studies; Female; Fractures, Bone; Humans; Knee Injuries; Male; Osteochondritis; Patella
PubMed: 35142232
DOI: 10.1177/03635465221073995 -
Archives of Orthopaedic and Trauma... Mar 2018Functional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee...
PURPOSE
Functional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee pain, limited range of motion and symptomatic hardware. The purpose of this study was to evaluate if removal of hardware is beneficial to symptomatic patients after patellar fracture fixation.
METHODS
Patients who presented to our institution between December 2006 and November 2014 with patella fractures treated with ORIF were eligible for inclusion. Patella ORIF was performed using (1) K-wires (KW) with a tension band construct or (2) Cannulated Screws (CS) with a tension band construct. Radiological analyses included (1) AO classification and (2) measurements of prominent hardware length. Patient medical charts were reviewed for demographic and intraoperative data as well as peri/postoperative complications. All patients completed the SF-12 score, visual analog scale, Kujala score, Lysholm score and questionaries' regarding return to previous activity levels.
RESULTS
Forty-seven patients met the inclusion criteria. The average time from fracture fixation to removal of hardware was 15.8 (SD ± 14.9) months. The mean follow-up was 43.1 (SD ± 27.1) months. Patella fixation was accomplished using tension band constructs with KW in 28 patients (59.5%) or with CS in 19 patients (40.5%). Patient reported quality of life and pain outcomes improved significantly after removal of hardware (p = 0.001, and p = 0.002 respectively). Functional outcome scores (Kujala and Lysholm) did not improve significantly after hardware removal in the KW or CS groups. Significantly more patients in the KW group returned to pre-injury activity (p = 0.005).
CONCLUSIONS
Hardware removal after patella ORIF significantly improves patient reported pain and quality of life outcomes but not functional outcomes. Patients should be counseled regarding the expected outcome of hardware removal following patella ORIF and diabetic patients should be given special consideration before undergoing this procedure.
Topics: Adult; Bone Screws; Bone Wires; Device Removal; Female; Follow-Up Studies; Fracture Fixation, Internal; Fractures, Bone; Humans; Lysholm Knee Score; Male; Middle Aged; Open Fracture Reduction; Patella; Quality of Life; Recovery of Function; Retrospective Studies; Visual Analog Scale
PubMed: 29185046
DOI: 10.1007/s00402-017-2852-2 -
Arthroscopy : the Journal of... Dec 2021While trochlear dysplasia is commonly discussed as a major risk factor for recurrent patellar instability, it also has a strong relationship with the development of...
Editorial Commentary: Stabilize the Patella to Achieve Functional Gain but Don't Neglect the Cartilage That May Cause Long-Term Pain! Trochlear Dysplasia Plays a Role in Both.
While trochlear dysplasia is commonly discussed as a major risk factor for recurrent patellar instability, it also has a strong relationship with the development of patellofemoral cartilage lesions. Patellofemoral instability frequently occurs in teens and young adults, and the high prevalence of associated cartilage damage unfortunately sets patients up for the progression of degenerative changes of the patellofemoral joint at an early age. The judicious use of magnetic resonance imaging can help identify the presence of chondral lesions, allowing for urgent management of associated osteochondral fractures or open discussions and patient education about the possibility of performing a cartilage restoration procedure concurrently with patellar stabilization surgery. The location and presence of patellofemoral chondral lesions should be considered when contemplating the concurrent use of tibial tubercle osteotomy as part of the patellar stabilization procedure.
Topics: Adolescent; Cartilage; Humans; Joint Instability; Pain; Patella; Patellofemoral Joint; Young Adult
PubMed: 34863383
DOI: 10.1016/j.arthro.2021.06.015 -
The Iowa Orthopaedic Journal 2017This study aims to provide biomechanical data on the effect of patella height in the setting of medial patellofemoral ligament (MPFL) reconstruction using finite element...
BACKGROUND
This study aims to provide biomechanical data on the effect of patella height in the setting of medial patellofemoral ligament (MPFL) reconstruction using finite element analysis. The study will also examine patellofemoral joint biomechanics using variable femoral insertion sites for MPFL reconstruction.
METHODS
A previously validated finite element knee model was modified to study patella alta and baja by translating the patella a given distance to achieve each patella height ratio. Additionally, the models were modified to study various femoral insertion sites of the MPFL (anatomic, anterior, proximal, and distal) for each patella height model, resulting in 32 unique scenarios available for investigation.
RESULTS
In the setting of patella alta, the patellofemoral contact area decreased, resulting in a subsequent increase in maximum patellofemoral contact pressures as compared to the scenarios with normal patellar height. Additionally, patella alta resulted in decreased lateral restraining forces in the native knee scenario as well as following MPFL reconstruction. Changing femoral insertion sites had a variable effect on patellofemoral contact pressures; however, distal and anterior femoral tunnel malpositioning in the setting of patella alta resulted in grossly elevated maximum patellofemoral contact pressures as compared to other scenarios.
CONCLUSIONS
Patella alta after MPFL reconstruction results in decreased lateral restraining forces and patellofemoral contact area and increased maximum patellofemoral contact pressures. When the femoral MPFL tunnel is malpositioned anteriorly or distally on the femur, the maximum patellofemoral contact pressures increase with severity of patella alta.
CLINICAL RELEVANCE
When evaluating patients with patellofemoral instability, it is important to recognize patella alta as a potential aggravating factor. Failure to address patella alta in the setting of MPFL femoral tunnel malposition may result in even further increases in patellofemoral contact pressures, making it essential to optimize intraoperative techniques to confirm anatomic MPFL femoral tunnel positioning.
Topics: Biomechanical Phenomena; Finite Element Analysis; Humans; Joint Instability; Models, Anatomic; Patella; Patellofemoral Joint
PubMed: 28852343
DOI: No ID Found