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British Journal of Sports Medicine May 2021To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT). (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT).
METHODS
In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence.
RESULTS
Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33).
CONCLUSIONS
In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT.
Topics: Adult; Exercise Therapy; Female; Humans; Intention to Treat Analysis; Male; Netherlands; Pain Measurement; Patella; Patient Compliance; Patient Satisfaction; Return to Sport; Single-Blind Method; Tendinopathy; Treatment Outcome; Ultrasonography; Young Adult
PubMed: 33219115
DOI: 10.1136/bjsports-2020-103403 -
Journal of Athletic Training Jul 2022Patellar tendinopathy is a common yet misunderstood condition that afflicts a variety of patient populations. This lack of understanding affects the ability of... (Review)
Review
Patellar tendinopathy is a common yet misunderstood condition that afflicts a variety of patient populations. This lack of understanding affects the ability of clinicians to provide effective treatment interventions. Patients with tendinopathy often report long-term and low to moderate levels of pain, diminished flexibility, and reduced strength, as well as decreased physical function. Load-management strategies combined with exercise regimens focused on progressive tendon loading are the most effective treatment options for patients with patellar tendinopathy. This review will provide an evidence-based approach to patellar tendinopathy, including its pathoetiology, evaluation, and treatment strategies.
Topics: Humans; Patellar Ligament; Tendinopathy; Patella; Treatment Outcome; Pain
PubMed: 34623447
DOI: 10.4085/1062-6050-0049.21 -
Stem Cell Research & Therapy Jul 2021Chondromalacia patellae (CMP), also known as runner's knee, typically occurs in young patients, which is characterized by anterior knee pain (AKP) that is associated... (Review)
Review
Chondromalacia patellae (CMP), also known as runner's knee, typically occurs in young patients, which is characterized by anterior knee pain (AKP) that is associated with visible changes in patellar cartilage. The initial pathological changes include cartilage softening, swelling, and edema. CMP is caused by several factors, including trauma, increased cartilage vulnerability, patellofemoral instability, bony anatomic variations, abnormal patellar kinematics, and occupation hazards. CMP may be reversible or may progress to develop patellofemoral osteoarthritis. Quadriceps wasting, patellofemoral crepitus, and effusion are obvious clinical indications. Additionally, radiological examinations are also necessary for diagnosis. Magnetic resonance imaging (MRI) is a non-invasive diagnostic method, which holds a promise in having the unique ability to potentially identify cartilage lesions. Modalities are conventionally proposed to treat cartilage lesions in the PF joint, but none have emerged as a gold standard, neither to alleviated symptoms and function nor to prevent OA degeneration. Recently, researchers have been focused on cartilage-targeted therapy. Various efforts including cell therapy and tissue emerge for cartilage regeneration exhibit as the promising regime, especially in the application of mesenchymal stem cells (MSCs). Intra-articular injections of variously sourced MSC are found safe and beneficial for treating CMP with improved clinical parameters, less invasiveness, symptomatic relief, and reduced inflammation. The mechanism of MSC injection remains further clinical investigation and is tremendously promising for CMP treatment. In this short review, etiology, MRI diagnosis, and treatment in CMP, especially the treatment of the cell-based therapies, are reviewed.
Topics: Cartilage, Articular; Cell- and Tissue-Based Therapy; Chondromalacia Patellae; Humans; Knee Joint; Magnetic Resonance Imaging; Osteoarthritis, Knee; Patella
PubMed: 34275494
DOI: 10.1186/s13287-021-02478-4 -
Swiss Medical Weekly Jan 2020The role of the patella is paramount in the transmission of the quadriceps muscle forces, the increase of the lever arm, the distribution of the forces on the trochlea... (Review)
Review
The role of the patella is paramount in the transmission of the quadriceps muscle forces, the increase of the lever arm, the distribution of the forces on the trochlea and the centring of the extensor apparatus. Despite the low incidence of patellar factures in comparison with other lower limb fractures, the painful and functional complications, such as knee stiffness, loss of extension and patellofemoral osteoarthritis, can be very disabling and will often compromise the return to a professional or recreational activity and induce falls in the elderly population. Treatment can be conservative or surgical, provided that it is adapted to the type of fracture. Undisplaced fractures with an intact extensor mechanism can be treated nonoperatively. Surgical treatment is recommended for fractures that either disrupt the extensor mechanism or have more than 2 to 3 mm of step-off and more than 1 to 4 mm of displacement. Tension band fixation is the most commonly employed surgical technique. In most cases, hardware has to be removed after fracture healing because of implant-related pain. Operative treatment of comminuted patellar fractures presents a significant challenge to surgeons. Failure to restore the articular surface contour results in posttraumatic arthritis. Anatomical reconstruction of the articular surface is the only way to prevent the development of posttraumatic osteoarthritis. Typically, fracture classification and thus treatment choice are based on anteroposterior and lateral radiographs of the knee, but when computed tomography of the knee was performed pre-operatively, both the classification and treatment were modified thanks to a better understanding of the fracture complexity. The purpose of this article is to review current treatment strategies and optimise the management of adult patients with patellar fractures.
Topics: Fractures, Bone; Humans; Knee Injuries; Orthopedic Procedures; Patella
PubMed: 31940427
DOI: 10.4414/smw.2020.20165 -
Journal of the American Academy of... Jul 2022The lateral patellofemoral joint soft tissues contain key structures that surround and balance the joint. These structures can affect joint tracking, stability, and... (Review)
Review
The lateral patellofemoral joint soft tissues contain key structures that surround and balance the joint. These structures can affect joint tracking, stability, and force distribution. It is important to understand the lateral patellofemoral anatomy and biomechanics, and their relationship with patellofemoral instability, anterior knee pain, and osteoarthritis. Lateral-sided surgical procedures such as lateral release, lateral retinacular lengthening, and partial lateral patellar facetectomy can be useful in the treatment of such patellofemoral problems.
Topics: Arthroplasty, Replacement, Knee; Biomechanical Phenomena; Knee Joint; Patella; Patellofemoral Joint
PubMed: 35858252
DOI: 10.5435/JAAOSGlobal-D-21-00255 -
Acta Bio-medica : Atenei Parmensis Mar 2022The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture...
BACKGROUND
The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures.
METHODS
The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with an AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system.
RESULTS
Twelve patients (2 males and 10 females) with a mean age of 67,8 years were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded.
CONCLUSIONS
The modified swashbuckler approach allows anatomical reduction and appropriate fixation without sacrificing the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.
Topics: Activities of Daily Living; Bone Plates; Female; Femoral Fractures; Fracture Fixation, Internal; Fracture Healing; Humans; Male; Patella; Treatment Outcome
PubMed: 35315401
DOI: 10.23750/abm.v93i1.12091 -
Journal of Orthopaedic Surgery and... Jun 2021Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation.
METHODS
A prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation. The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up. Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples.
DISCUSSION
Although several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient's anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella.
TRIAL REGISTRATION
The study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov .
Topics: Biosimilar Pharmaceuticals; Braces; Conservative Treatment; Female; Humans; Male; Orthopedic Procedures; Osteoarthritis, Knee; Patella; Patellar Dislocation; Patellofemoral Joint; Physical Therapy Modalities; Prospective Studies; Recurrence; Secondary Prevention; Time Factors; Treatment Outcome
PubMed: 34120628
DOI: 10.1186/s13018-021-02513-3 -
Archives of Orthopaedic and Trauma... Oct 2021The purpose of this study was to describe the indications and technical aspects as well as evaluate the clinical and functional outcome of lengthening osteotomy of the...
INTRODUCTION
The purpose of this study was to describe the indications and technical aspects as well as evaluate the clinical and functional outcome of lengthening osteotomy of the lateral trochlear ridge in patients with patellofemoral pain and/or patella instability and presence of trochlear dysplasia Dejour type A or lack of Dejour type dysplasia and short lateral articular trochlea.
MATERIALS AND METHODS
Six consecutive adult patients were treated with a lateral trochlear lengthening osteotomy. Five patients received a concomitant medial patellofemoral ligament reconstruction. Three patients had prior patella stabilization surgeries. Trochlea dysplasia (Dejour classification), Caton-Dechamps index, tibial tubercle trochlear groove (TT-TG) distance, patellar tilt and lateral condylar index were measured in preoperative MRIs. Clinical and functional evaluation included the Kujala Anterior Knee Pain Scale, the Lysholm Knee Score, the Tegner Activity Score, a subjective evaluation form and isokinetic muscle strength.
RESULTS
Four patients had a Dejour type A dysplasia, two patients had no dysplasia. The mean (range) Caton-Dechamps index was 1.09 (0.95-1.16), TT-TG distance 10.9 mm (9.2-15.6 mm), patellar tilt 15° (4-32°) and lateral condylar index 82.0% (74-90%). One patient was lost to follow up, all others were followed for 2-5 years. All patients were satisfied with the clinical outcome. The Lysholm score increased from 55 (37-79) to 89 (76-100), the Tegner activity score from 3.6 (2-6) to 5.6 (5-7). The Kujala score postoperative was 90 (75-96). Some but not all patients had full strength recovery compared to the contralateral leg.
CONCLUSION
We recommend measuring the lateral condylar index and considering the indication of a lateral trochlear lengthening osteotomy as an additional or isolated procedure in selected patients with trochlear dysplasia Dejour type A or lack of dysplasia and short lateral articular trochlea depending on the extent of the patellar instability.
LEVEL OF EVIDENCE
Level IV, Case Series.
TRIAL REGISTRATION NUMBER
NCT04378491, clinicaltrials.gov, May 7, 2020.
Topics: Adult; Humans; Joint Instability; Knee Joint; Ligaments, Articular; Osteotomy; Patella; Patellar Dislocation; Patellofemoral Joint
PubMed: 33625541
DOI: 10.1007/s00402-020-03736-5 -
European Journal of Human Genetics :... Aug 2023High-throughput sequencing has become a standard first-tier approach for both diagnostics and research-based genetic testing. Consequently, this hypothesis-free... (Review)
Review
High-throughput sequencing has become a standard first-tier approach for both diagnostics and research-based genetic testing. Consequently, this hypothesis-free testing manner has revealed the true breadth of clinical features for many established genetic disorders, including Meier-Gorlin syndrome (MGORS). Previously known as ear-patella short stature syndrome, MGORS is characterized by growth delay, microtia, and patella hypo/aplasia, as well as genital abnormalities, and breast agenesis in females. Following the initial identification of genetic causes in 2011, a total of 13 genes have been identified to date associated with MGORS. In this review, we summarise the genetic and clinical findings of each gene associated with MGORS and highlight molecular insights that have been made through studying patient variants. We note interesting observations arising across this group of genes as the number of patients has increased, such as the unusually high number of synonymous variants affecting splicing in CDC45 and a subgroup of genes that also cause craniosynostosis. We focus on the complicated molecular genetics for DONSON, where we examine potential genotype-phenotype patterns using the first 3D structural model of DONSON. The canonical role of all proteins associated with MGORS are involved in different stages of DNA replication and in addition to summarising how patient variants impact on this process, we discuss the potential contribution of non-canonical roles of these proteins to the pathophysiology of MGORS.
Topics: Female; Humans; Congenital Microtia; Patella; Growth Disorders; Micrognathism
PubMed: 37059840
DOI: 10.1038/s41431-023-01359-z -
RoFo : Fortschritte Auf Dem Gebiete Der... Sep 2021Throughout the literature, patellofemoral instability (PI) is defined as an increased risk of re-/luxation of the patella within the patellofemoral joint (PFJ). In... (Review)
Review
BACKGROUND
Throughout the literature, patellofemoral instability (PI) is defined as an increased risk of re-/luxation of the patella within the patellofemoral joint (PFJ). In most patients it is caused by traumatic patella luxation or the existence of a range of predisposing anatomic risk factors leading to an unphysiological movement sequence within the PFJ also known as patellofemoral maltracking. In order to provide an individualized therapy approach, clinical and radiological evaluation of those risk factors of variable magnitude becomes essential. Diagnostic imaging such as magnetic resonance imaging (MRI), plain radiography, and computed tomography (CT) are straightforward diagnostic tools in terms of evaluation and treatment of PI.
METHOD
In this review we performed a precise analysis of today's literature concerning the radiological evaluation of anatomic risk factors leading to PI. The purpose of the review is to present a logical compilation of the different anatomical risk factors causing PI and provide a straight overview of valuable radiological imaging techniques.
RESULTS AND CONCLUSION
PI is frequently based on a multifactorial disposition. The most relevant predisposing risk factors are trochlea dysplasia, rupture of the medial patellofemoral ligament (MPFL), patella alta, abnormal tibial tubercle to trochlea groove distance (TT-TG), femoral torsion deformities, and genu valgum. Although plain X-rays may provide basic diagnostic value, cross-sectional imaging (MRI, CT) is the standard radiological tool in terms of evaluation and detection of severity of predisposing anatomic variants leading to PI.
KEY POINTS
· Based on today's literature, PI is characterized as an increased risk of patella re-/luxation within the PFJ.. · Underlying anatomic risk factors of variable magnitude mark the pathological cause of PI.. · Modern diagnostic imaging (MRI and CT) permits straightforward diagnosis of the typical features in terms of PI.. · To provide an individualized therapy approach, precise radiological evaluation and determination of the severity of predisposing anatomic anomalies are essential..
CITATION FORMAT
· Maas KJ, Warncke ML, Leiderer M et al. Diagnostic Imaging of Patellofemoral Instability. Fortschr Röntgenstr 2021; 193: 1019 - 1033.
Topics: Humans; Ligaments, Articular; Magnetic Resonance Imaging; Patella; Patellar Dislocation; Patellofemoral Joint; Tibia
PubMed: 33773517
DOI: 10.1055/a-1348-2122