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Knee Surgery, Sports Traumatology,... Jun 2024This study aimed to investigate the development of patellofemoral joint (PFJ) cartilage lesions following anterior cruciate ligament reconstruction (ACLR) using...
PURPOSE
This study aimed to investigate the development of patellofemoral joint (PFJ) cartilage lesions following anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) autograft through a systematic review.
METHODS
A comprehensive search was conducted in PubMed, Embase, Cochrane Library and Google Scholar databases to find articles published from database inception until 15 November 2023. The search terms were [('Anterior Cruciate Ligament' [mesh] OR 'anterior cruciate ligament' OR 'ACL') AND 'reconstruction' AND 'cartilage' AND ('second look arthroscopy' OR 'second-look arthroscopy' OR 'MRI' OR 'magnetic resonance imaging')]. Inclusion criteria were studies that reported on the occurrence of PFJ cartilage lesions following ACLR using HT autograft, as determined by second-look arthroscopy or follow-up magnetic resonance imaging (MRI).
RESULTS
Fifteen studies (1084 patients) met the inclusion criteria, with follow-up periods ranging from 1 to 5 years. In the results of second-look arthroscopy, cartilage grade deterioration was observed, ranging from MDs of 0.1 to 2.0 in the patella and from 0 to 1.0 in the trochlea. Follow-up MRI results reported the incidence of PFJ cartilage degeneration with rates ranging from 20% to 44%. Patient-reported outcome measures often showed no significant association with PFJ cartilage lesions. The studies included in this review reported various risk factors for cartilage lesion development.
CONCLUSION
Cartilage lesions in the PFJ, detected using second-look arthroscopy or follow-up MRI, frequently develop shortly after ACLR using HT autograft. At this stage, patients might not show specific symptoms; however, those with risk factors require careful observation and evaluation by clinicians during follow-up.
LEVEL OF EVIDENCE
Level IV.
PubMed: 38932612
DOI: 10.1002/ksa.12339 -
Danish Medical Journal Jun 2024In orthopaedics, anterior cruciate ligament (ACL) reconstructions are among the most common surgical interventions. Two methods are preferably used: autografts from the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
In orthopaedics, anterior cruciate ligament (ACL) reconstructions are among the most common surgical interventions. Two methods are preferably used: autografts from the hamstring tendon (HT) or patella tendon (PT). The purpose of this meta-analysis was to compare these two methods when returning to sports.
METHODS
Eleven studies were included based on a literature search conducted in PubMed. The primary outcome was return to preinjury sport level in athletes. Post-operative results such as the Lysholm score, the International Knee Documentation Committee (IKDC) subjective score, the Tegner Activity Score and KT-1000 arthrometry and autograft re-rupture rates were analysed as secondary outcomes.
RESULTS
The analysis showed no significant difference in return to preinjury sports level at a two-year follow-up between patients operated with hamstring or patella autograft. Considering the secondary outcomes, no significant differences were recorded in Lysholm score, IKDC score or re-rupture rate. The Tegner Activity Scale demonstrated a significantly higher activity level in the PT group than in the HT group (OR 0.79, p = 0.003). At the two-year follow-up, the KT-1000 arthrometer analysis also showed a significant difference in laxity, which was higher for the HT autografts (OR -0.31, p = 0.02).
CONCLUSION
This study showed no significant differences between hamstring and patella autografts. Even so, the choice of method when operated for ACL rupture remains crucial for the individual and should be a weighted decision made jointly by the patient and the physician.
Topics: Humans; Return to Sport; Anterior Cruciate Ligament Reconstruction; Hamstring Tendons; Patellar Ligament; Anterior Cruciate Ligament Injuries; Autografts; Transplantation, Autologous; Treatment Outcome
PubMed: 38903025
DOI: 10.61409/A09230599 -
Orthopaedic Journal of Sports Medicine Jun 2024While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of... (Review)
Review
BACKGROUND
While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes.
PURPOSE
To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique.
STUDY DESIGN
Systematic review.
METHODS
A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups.
RESULTS
Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt.
CONCLUSION
Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.
PubMed: 38855071
DOI: 10.1177/23259671241241537 -
Journal of Experimental Orthopaedics Jul 2024Patellofemoral joint instability (PFJI) can surgically be treated with a multitude of approaches, depending on the underlying pathology. In the presence of increased... (Review)
Review
Promising results following derotational femoral osteotomy in patellofemoral instability with increased femoral anteversion: A systematic review on current indications, outcomes and complication rate.
PURPOSE
Patellofemoral joint instability (PFJI) can surgically be treated with a multitude of approaches, depending on the underlying pathology. In the presence of increased femoral anteversion, some authors have reported good results with a derotational distal femoral osteotomy (DeDFO). The purpose of the study was to investigate the indications, outcomes and complication rate of DeDFO for PFJI.
METHODS
A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching Medline, Embase, Web of Science and Cochrane Library databases through 1 December 2023. Included were levels 1-4 clinical studies of skeletally mature patients undergoing a DeDFO for PFJI irrespective of concomitant procedures. Study characteristics, indications, radiological and clinical outcomes, surgical technique and concomitant procedures, re-dislocation and complication rate were all analysed, as was methodological quality.
RESULTS
A total of 12 studies including 310 patients (325 knees) were included. Three studies were cohort studies, all others were case series. The mean patient age across the studies was 22 years, and the mean follow-up was 29.4 months. Femoral anteversion cut-off was between 20° and 30°. Every study included at least one concurrent soft tissue, bony or combined procedure. Across all studies, one case of re-dislocation was reported (0.3%) and four implant or osteotomy-related complications (1.2%) were reported. All studies reported a statistically significant increase in clinical scores.
CONCLUSION
This systematic review of DeDFO for patellofemoral instability in the presence of increased femoral anteversion demonstrates promising clinical results and an extremely low dislocation and complication rate. The heterogeneity of the cut-off in anteversion and concomitant procedures, especially tibial tubercle osteotomy with seemingly identical results, indicates the need for high-quality evidence for treating patellofemoral instability. Based upon this systematic review, we strongly recommend that DeDFO be added to the 'menu à la carte' of PFJI.
LEVEL OF EVIDENCE
Level III Systematic Review.
PubMed: 38774579
DOI: 10.1002/jeo2.12032 -
The Journal of Arthroplasty May 2024In the setting of total knee arthroplasty (TKA), prior patellectomy historically prompted the use of increased constraint implants, specifically posterior-stabilized...
Prior Patellectomy: A Systematic Review and Meta-Analysis Comparing Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty Survivorship and Reported Outcomes.
BACKGROUND
In the setting of total knee arthroplasty (TKA), prior patellectomy historically prompted the use of increased constraint implants, specifically posterior-stabilized (PS) designs. However, modern case series have reported similar outcomes utilizing cruciate-retaining (CR) implants. The primary outcome of this study was to compare implant retention rates between these 2 implant designs in prior patellectomy patients. Secondary outcomes included a comparison of patient-reported outcome scores and cause for revision.
METHODS
A comprehensive systematic review was performed using Web of Science, PubMed, and Scopus databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Boolean operator search terms included "patellectomy AND (arthroplasty) OR (replacement)." Case reports, review articles, < 2 years of follow-up, and studies in which the implant design could not be ascertained were excluded. An initial screening of titles and abstracts for inclusion was performed, followed by a full manuscript review of eligible articles. Single-data extraction was performed, followed by subsequent statistical analysis.
RESULTS
A total of 9 studies (209 knees) met the inclusion criteria. The average time from patellectomy to TKA was 16.1 years. While all patients had significant improvement in functional outcomes, CR implants displayed proportionally greater improvement in Knee Society Scores compared to PS implants (+108 versus +98%, P ≤ .001). However, there was a significantly greater rate of revision in the CR cohort compared to PS (18.6 versus 2.6%, P = .002).
CONCLUSIONS
Prior patellectomy patients undergoing TKA have significant improvements in patient-reported functional outcomes and high midterm retention rates. While CR implant designs portend a potentially greater improvement in functional outcomes, they also have a greater risk for revision than their PS implant counterparts. However, contemporary implant designs and operative techniques likely render revision rates equivocal between CR and PS implants in postpatellectomy patients.
PubMed: 38734324
DOI: 10.1016/j.arth.2024.05.002 -
The Knee Jun 2024Children and adolescents have the highest incidence of patellar instability among the population. We aimed to identify patho-morphological and epidemiological factors... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Children and adolescents have the highest incidence of patellar instability among the population. We aimed to identify patho-morphological and epidemiological factors associated with patellar instability, and to identify factors predisposing to recurrence in children and adolescents.
METHODS
Published and unpublished literature databases, conference proceedings and the reference lists of included studies were searched to the 14th of March 2024. Studies were eligible if they compared history characteristics, examination features and radiological parameters between patients with and without instability, or evaluated risk factors for instability recurrence. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design.
RESULTS
The evidence was moderate to low in quality. Forty-five studies (including 9000 patients) were eligible. Tibial tubercle - tibial groove (TT-TG) distance (weighted mean difference [WMD] 5.96 mm, 95% Confidence Interval [CI]: 4.94 to 6.99 mm), sulcus angle (WMD: 13.93˚, 95% CI: 9.1˚ to 18.8˚), and Insall-Salvati index (WMD: 0.2, 95% CI: 0.16 to 0.23) were greater in patients with patellar instability. Risk factors for recurrent dislocation included age less than 18 years (Odds ratio [OR]: 2.56, 95% CI: 1.63 to 4.0), skeletal immaturity (OR: 1.79, 95% CI: 1.21 to 2.64) and presence of trochlear dysplasia (OR: 3.37, 95% CI: 1.85 to 6.15).
CONCLUSION
Knowledge of patho-morphological factors associated with patellar instability could help explain its pathophysiological processes, allowing for the design of treatment approaches and the identification of patients at risk.
Topics: Humans; Joint Instability; Adolescent; Child; Patellar Dislocation; Risk Factors; Patella; Recurrence
PubMed: 38657526
DOI: 10.1016/j.knee.2024.03.009 -
Journal of Bodywork and Movement... Jan 2024The speculation of dynamic knee valgus (DKV) correlates with kinetic changes in the frontal plane that increased loading patellofemoral joint (PFJ). Therefore, it is the... (Meta-Analysis)
Meta-Analysis Review
The speculation of dynamic knee valgus (DKV) correlates with kinetic changes in the frontal plane that increased loading patellofemoral joint (PFJ). Therefore, it is the purpose of this systematic review and meta-analysis study is the effect of kinetic factors DKV on patellofemoral pain (PFP). The search strategy was carried out in the electronic databases of Cochrane Library, PubMed, Springer Link, Science Direct, Scopus. Studies limited to the period 2000 to 2020 were extracted. The quality of study was assessment by modified Downs and Black checklist. Mean and standard deviation were also used to calculate the effect size. There were selected 8 articles for the systematic review and Meta-analysis. The results showed that in PFP patients compared to healthy individuals have increase knee abduction moment (SMD = 0.75; 95% CI = [0.47 to 1.02]) and impulse (SMD = 0.79; 95% CI = [0.50 to 1.07]). Furthermore, PFP patients compared to healthy individuals have decrease onset (SMD = -0.60; 95% CI = [-1.03 to -0.17]) and during (SMD = -0.93; 95% CI = [-1.57 to -0.29]) gluteus medius (GMED); vis-à-vis, PFP patients compared to healthy individuals have increase onset (SMD = 0.10; 95% CI = [-0.34 to 0.54]) and during (SMD = 0.29; 95% CI = [-0.15 to 0.73]) adductors longus (AL). As a result; PFP patients compared to healthy individuals show decrease co-contraction GMED/AL (SMD = -1.03; 95% CI = [-1.83 to -0.24]). The kinetic factors of DKV of leading to PFJ contact area decreases and the loading in a smaller contact area on PFJ in the outer part of the patella. Eventually, this abnormal distribution of contact pressure leads to etiology and osteoarthritis of the PFP.
Topics: Humans; Patellofemoral Pain Syndrome; Knee Joint; Patella; Health Status
PubMed: 38432813
DOI: 10.1016/j.jbmt.2023.11.001 -
Healthcare (Basel, Switzerland) Feb 2024Patellar tendinopathy is a degenerative clinical disorder that causes load-related pain in the lower pole of the patella or patellar tendon. It predominantly affects... (Review)
Review
BACKGROUND
Patellar tendinopathy is a degenerative clinical disorder that causes load-related pain in the lower pole of the patella or patellar tendon. It predominantly affects young male athletes engaged in sports involving repetitive tendon loading, particularly explosive jumping. The combination of manual techniques with therapeutic exercise is hypothesized to provide greater benefits than exercise alone.
OBJECTIVE
The aim of this study is to analyze the scientific evidence regarding the effects of soft-tissue techniques combined with therapeutic exercise versus therapeutic exercise alone on pain intensity and function in individuals with patellar tendinopathy.
METHODS
A systematic review with meta-analysis was conducted following the PRISMA guidelines. PubMed, Lilacs, IBECS, CENTRAL, WOS, SciELO, Academic Search, CINAHL, SportDiscus, PEDro, and Google Scholar databases were consulted. Randomized controlled trials and quasi-randomized trials focusing on the effects of soft-tissue techniques combined with therapeutic exercise (experimental group) versus therapeutic exercise alone (control group) on pain and function in individuals aged 16 years and older with patellar tendinopathy were selected. The Cochrane tool for risk-of-bias assessment and the PEDro scale for methodological quality were used.
RESULTS AND DISCUSSION
A total of six studies ( = 309; age range = 16-40 years), considered to have a low risk of bias and moderate-to-high methodological quality, were included. The results showed improvements in function in the experimental group (mean of 60% on the Visa-P scale) and pain in the experimental group (mean decrease of 2 points in the VAS scale). There were improvements in 50% of the studies when comparing variables between the experimental and control groups.
CONCLUSIONS
The combination of manual techniques, such as dry needling, percutaneous electrolysis, transverse friction massage, and stretching, along with a squat on a 25° inclined plane, appears to be effective in the treatment of patellar tendinopathy. Static stretching of the quadriceps before and after the squat five times per week, along with dry needling or percutaneous electrolysis sessions twice a week for 8 weeks, is recommended. However, future studies analyzing groups with passive techniques versus therapeutic exercise are needed to standardize the treatment and establish the optimal dose.
PubMed: 38391804
DOI: 10.3390/healthcare12040427 -
Journal of ISAKOS : Joint Disorders &... Jun 2024Patellofemoral instability (PFI) has multiple predisposing anatomic factors, including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea... (Review)
Review
Femoral internal torsion greater than twenty-five degrees and/or external tibial torsion greater than thirty degrees as measured by computed tomography are threshold values for axial alignment correction in patellofemoral instability.
OBJECTIVES
Patellofemoral instability (PFI) has multiple predisposing anatomic factors, including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea dysplasia, excessive lateral patellar tilt, and excessive lateral Q vector. Yet, few studies have analyzed surgical thresholds for performing axial alignment corrective osteotomies in the treatment of PFI and patella maltracking. The objective of this systematic literature review was to determine if there is a threshold for axial plane alignment that triggers surgical correction for the treatment of patellar instability in the published literature.
METHODS
Using a predetermined search strategy, a systematic literature search of 10 major databases and gray literature resources was completed. Only studies reporting on patellar instability and outcomes were included. Radiologic indications, additional procedures, outcomes, and complications were reported. Titles and abstracts were screened, and full-text manuscripts were then selected and extracted. Variables related to radiographic and clinical parameters, patient demographics, surgery performed, surgical correction, complications, and reoperations were recorded preoperatively and postoperatively.
RESULTS
A total of 1132 abstracts and titles were screened by two reviewers, yielding 15 eligible studies. The reported threshold identified in our study for axial plane alignment that triggers surgical correction in most of the published literature when discussing PFI was either tibial torsion greater than 30° and/or femoral anteversion greater than 25°. Following rotational osteotomy of one or both long bones, one study (7%) reported improvements in tubercle-sulcus angle, two studies (13%) reported improvements in femoral-tibial angle, and four studies (27%) reported decreases in tibial torsion. For patient-reported outcomes, seven studies (47%) reported improvement in the Kujala score, five studies (33%) reported postoperative improvement in Lysholm, and four studies (27%) reported improvement in the International Knee Documentation Committee (IKDC) score. Nine studies (60%) reported preoperative femoral anteversion; however, only two studies compared pre- and post-operative values (one study reported a decrease in anteversion and another study reported an increase in anteversion).
CONCLUSION
When treating PFI, the reported threshold for axial plane alignment that triggers surgical correction in most of the published literature was tibial torsion greater than 30° and/or femoral anteversion greater than 25° as measured by CT. However, there is no consensus on the axial alignment measurement technique.
LEVEL OF EVIDENCE
III.
Topics: Humans; Joint Instability; Patellofemoral Joint; Femur; Tibia; Osteotomy; Tomography, X-Ray Computed; Patella; Female; Male
PubMed: 38365167
DOI: 10.1016/j.jisako.2024.02.002 -
Orthopaedic Journal of Sports Medicine Jan 2024Osteochondral injuries (OCIs) are common in patients with acute lateral patellar dislocation, which can produce both short- and long-;term adverse effects. However, the...
BACKGROUND
Osteochondral injuries (OCIs) are common in patients with acute lateral patellar dislocation, which can produce both short- and long-;term adverse effects. However, the pattern of these injuries warrants further analysis, especially in relation to patient age.
PURPOSE
To determine the overall prevalence of concomitant OCIs as well as the prevalence differences based on location and age after acute lateral patellar dislocations.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A comprehensive search of PubMed, Embase, Web of Science, and Cochrane Library was completed from inception to July 20, 2022. All articles reporting the prevalence of OCI were included. The sample characteristics such as age, study design, magnetic resonance imaging diagnostic data, and the number of patients with OCI were extracted. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment. The overall and per-;site injury rates were calculated, and the prevalence was stratified by age-;group (≤16 and >16 years) and compared.
RESULTS
The systematic review included 39 studies involving 3354 patients. MINORS scores were 11.94 ± 1.98 and 16 ± 3.46 in the noncomparative and comparative studies, respectively. The overall prevalence of bone bruises and OCI was 89.6% (95% CI, 77.4%-97.7%) and 48.8% (95% CI, 39.0%-58.7%), respectively. In both overall and >16-year-old patients, the lateral femoral condyle (LFC) was the most common site of bone bruise (90.5% [95% CI, 84.0%-95.6%] and 91.5% [95% CI, 84.3%-96.9%], respectively); however, the medial patellar bruise was more common in patients ≤16 years (89.2% [95% CI, 82.9%-94.4%]). Among the pooled sites of OCI, the medial patella accounted for the largest proportion (36.9% [95% CI, 28.0%-46.3%]). OCIs were more common in patients >16 years (52.6% [95% CI, 39.4%-65.6%]) than in patients ≤16 years (46.6% [95% CI, 33.2%-60.3%]).
CONCLUSION
Bone bruises on the LFC were most prevalent overall and in patients >16 years, whereas bone bruises on the medial patella were more prevalent in patients ≤16 years. OCIs were frequently seen in patients >16 years, with the most common site being the medial patella.
PubMed: 38274015
DOI: 10.1177/23259671231220904