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Journal of Orthopaedics Oct 2024Hypermobility describes the movement of joints beyond normal limits. Whether hypermobility predisposes to patellar instability is yet to be established. We aimed to... (Review)
Review
INTRODUCTION
Hypermobility describes the movement of joints beyond normal limits. Whether hypermobility predisposes to patellar instability is yet to be established. We aimed to determine if joint hypermobility leads to an increased risk of patellar instability, and to evaluate outcomes of treatment for patellar instability in those who exhibit hypermobility.
METHODS
Published and unpublished literature databases were searched to September 7, 2023. Studies comparing prevalence of patellar dislocation/differences in treatment outcomes in patients with and without hypermobility were included.
RESULTS
We identified 18 eligible studies (4,391 patients). The evidence was low in quality. A case series on 82 patients found that there was a relationship between generalised joint laxity and patellar instability. This was corroborated by a study comparing 104 patients with patellar dislocation to 110 patients without. Prevalence of generalised joint laxity was six time higher in the former (64.4% vs 10.9%, p < 0.001).Five studies found surgical intervention aimed at correcting patellar dislocation in patients with idiopathic hypermobility led to satisfactory outcomes. There was conflicting evidence regarding if hypermobile patients have worse outcomes than non-hypermobile patients following medial patellofemoral ligament reconstruction (MPFLR) in two studies. In addition, this procedure had a 19.1% failure rate in patients with Ehlers Danlos Syndrome (EDS), with hypermobility associated with a higher failure rate (p = 0.03). One study showed the type of graft used made no difference in outcome scores or re-dislocation rates (p > 0.5). Another study had 7/31 (22.6%) autografts which failed, compared to 2/16 allografts (12.5%) (p = 0.69).
CONCLUSION
Joint hypermobility is a risk factor for patellar instability. Identification of at-risk groups may aid prevention of dislocations and allow for appropriate treatment. Patients with EDS experience poor outcomes following patellar stabilization surgery, with post-operative monitoring required.
PubMed: 38784948
DOI: 10.1016/j.jor.2024.05.009 -
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 Orthopaedic Surgery and... Apr 2024Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in...
Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review.
BACKGROUND
Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion.
PURPOSE
To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion.
METHODS
A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed.
RESULTS
A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period.
CONCLUSION
For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.
Topics: Humans; Male; Female; Patellar Dislocation; Patellofemoral Joint; Patellar Ligament; Knee Joint; Joint Dislocations; Osteotomy; Ligaments, Articular; Joint Instability
PubMed: 38582853
DOI: 10.1186/s13018-024-04709-9 -
Knee Surgery, Sports Traumatology,... May 2024Trochleoplasty has become increasingly utilised to address patellar instability in the setting of severe trochlear dysplasia. There remains a paucity of literature on... (Meta-Analysis)
Meta-Analysis
PURPOSE
Trochleoplasty has become increasingly utilised to address patellar instability in the setting of severe trochlear dysplasia. There remains a paucity of literature on the outcomes of 'thick'- versus 'thin'-osteochondral flap trochleoplasty. The purpose of this study is to compare clinical and radiographic outcomes between patients with patellar instability with symptomatic trochlear dysplasia treated using a 'thick' versus 'thin' osteochondral flap trochleoplasty.
METHODS
A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Quality assessment of final articles was conducted by two blinded reviewers. Articles were separated based on the use of a 'thick' versus 'thin' flap trochleoplasty. Data collection consisted of recording the following variables: patient demographics, indications for trochleoplasty, mean follow-up time, additional procedures performed during trochleoplasty, patient-reported outcome measures (PROMs), radiographic outcomes (tibial tubercle-trochlear groove [TT-TG] distance, Caton-Deschamps Index [CDI] and sulcus angle [SA]) and the incidence of any postoperative complications and patellar redislocation rates.
RESULTS
A total of 24 studies, consisting of 927 patients, were identified as meeting inclusion criteria. A total of five papers described a 'thick' flap technique, while 19 papers described the use of a 'thin' flap technique. No significant difference in the mean improvement of Kujala scores was appreciated when comparing 'thick' versus 'thin' techniques (p > 0.05). Improvements in mean radiographic outcomes based on TT-TG, CDI and SA were observed in both 'thick' and 'thin' flap trochleoplasty groups. The overall redislocation rate was 0.35%.
CONCLUSION
No significant difference in Kujala scores was observed in patients undergoing trochleoplasty utilising 'thick' versus 'thin' technique, while improvements in mean TT-TG, CDI and SA were noted in both technique groups, with an overall redislocation rate of 0.35%.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Joint Instability; Surgical Flaps; Patellofemoral Joint; Patellar Dislocation; Femur; Treatment Outcome; Postoperative Complications
PubMed: 38494738
DOI: 10.1002/ksa.12108 -
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 -
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 -
Medical Sciences (Basel, Switzerland) Nov 2023(1) Background: Acute patella dislocation (APD) is a prevalent knee injury, with rates between 5.8-77.8 per 100,000. APD often results in repeat lateral patella... (Review)
Review
(1) Background: Acute patella dislocation (APD) is a prevalent knee injury, with rates between 5.8-77.8 per 100,000. APD often results in repeat lateral patella dislocations due to the instability of the medial patellofemoral ligament (MPFL). Non-operative treatments have a 50% recurrence rate. While autologous grafting for MPFL has been favored, surgeons are now exploring synthetic grafts. We aimed to assess the effectiveness of synthetic grafts in MPFL reconstruction surgeries for repeated patellar dislocations; (2) Methods: Our research was based on a thorough search from the National Institute of Health and Clinical Excellence Healthcare Databases, using the Modified Coleman Methodology Score for quality assessment; (3) Results: Six studies met the inclusion criteria. A total of 284 patients and 230 knees were included. Seventy-five percent of patients were graded to have excellent-good clinical outcomes using the Crosby and Insall Grading System. International Knee Documentation Committee score and Knee injury and Osteoarthritis Outcome Score scores showed 59% and 60% post-operative improvement, respectively; (4) Conclusions: All studies showed improvement in post-operative functional outcomes and report no serious adverse events. The 6 mm, LARS (Orthomedic Ltd., Dollard-des-Ormeaux, QC, Canada) proved to have the most improvement in post-operative outcomes when used as a double bundle graft.
Topics: Humans; Patellofemoral Joint; Joint Instability; Knee Joint; Patellar Dislocation; Ligaments, Articular
PubMed: 38132916
DOI: 10.3390/medsci11040075 -
Journal of Clinical Orthopaedics and... Oct 2023There is no consensus for management of patellar instability, even in the case of malalignment. The purpose of the review is to evaluate outcomes in the literature of...
PURPOSE
There is no consensus for management of patellar instability, even in the case of malalignment. The purpose of the review is to evaluate outcomes in the literature of MPFL reconstruction with and without tibial tubercle osteotomy.
METHODS
Two databases PubMed and Scopus were searched for studies comparing MPFL reconstruction with and without concomitant tibial tuberosity osteotomy. PRISMA guidelines were followed. Data on functional outcomes via Kujala score, redislocation rates and return to sport rates were reported.
RESULTS
9 studies included data from 806 knees: 463 submitted to isolated MPFL reconstruction, and 343 submitted to the combined surgery. Patients submitted to the combined procedure had all TT-TG values superior to 18, while the ones with isolated reconstruction had more heterogeneous values, varying between 13 and 20 mm. 77.78% of the studies reported on postoperative Kujala scores, with a mean value of 83.53 in patients who underwent MPFL reconstruction alone and 83.72 in those who underwent the combined procedure. The mean difference between the two groups was -0.83, with the improvement of the score statistically significant in 22.22% of the studies, regardless of the surgery. Concerning redislocation rate, odds ratio comparing both procedures was 0.84 (p = 0.67).
CONCLUSION
The principal finding is that the MPFL reconstruction with or without TTO resulted in similar functional outcomes, assessed by the Kujala score, and low complications concerning recurrent patellar dislocation. More robust literature is needed in the setting of a high TT-TG distance.
LEVEL OF EVIDENCE
IV.
PubMed: 38044955
DOI: 10.1016/j.jcot.2023.102277 -
Outcomes Following Medial Patellofemoral Ligament Reconstruction with Allograft A Systematic Review.Bulletin of the Hospital For Joint... Dec 2023The purpose of this study was to systematically review the evidence in the literature in order to evaluate the outcomes following medial patellofemoral ligament (MPFL)...
PURPOSE
The purpose of this study was to systematically review the evidence in the literature in order to evaluate the outcomes following medial patellofemoral ligament (MPFL) reconstruction with allograft compared to autograft reconstruction.
METHODS
A systematic literature search was performed based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Inclusion criteria for the study was clinical studies reporting on MPFL reconstruction with allograft. Recurrence rate, complications, rate of return-to-play, and functional outcomes including the Kujala, Tegner, and visual analog scale (VAS) scores were evaluated. Statistical analysis was performed using GraphPad Prism 8.3.
RESULTS
Our review identified 12 studies with a total of 336 patient knees meeting the inclusion criteria. The majority of patients were female (61.6%), with a mean age of 22.3 years and a mean follow-up of 43.4 months. The overall rate of recurrence of lateral patellar instability was 2.7% in the allograft cohort as compared to 7.8% in the autograft cohort (p = 0.01). The mean Kujala score was 91.8%, and the mean VAS score was 1.3 at final follow-up. Additionally, 81.5% of patients were able to return to play in the studies reporting this outcome measure. The overall complication rate was 1.4%.
CONCLUSION
The overall rate of recurrence was lower following MPFL reconstruction with allograft as compared to autograft in the treatment of lateral patellar instability. Additionally, there were excellent patient reported outcomes and a low complication rate following the use of allograft for MPFL reconstructionPurpose: The purpose of this study was to systematically review the evidence in the literature in order to evaluate the outcomes following medial patellofemoral ligament (MPFL) reconstruction with allograft compared to autograft reconstruction.
METHODS
A systematic literature search was performed based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Inclusion criteria for the study was clinical studies reporting on MPFL reconstruction with allograft. Recurrence rate, complications, rate of return-to-play, and functional outcomes including the Kujala, Tegner, and visual analog scale (VAS) scores were evaluated. Statistical analysis was performed using GraphPad Prism 8.3.
RESULTS
Our review identified 12 studies with a total of 336 patient knees meeting the inclusion criteria. The majority of patients were female (61.6%), with a mean age of 22.3 years and a mean follow-up of 43.4 months. The overall rate of recurrence of lateral patellar instability was 2.7% in the allograft cohort as compared to 7.8% in the autograft cohort (p = 0.01). The mean Kujala score was 91.8%, and the mean VAS score was 1.3 at final follow-up. Additionally, 81.5% of patients were able to return to play in the studies reporting this outcome measure. The overall complication rate was 1.4%.
CONCLUSION
The overall rate of recurrence was lower following MPFL reconstruction with allograft as compared to autograft in the treatment of lateral patellar instability. Additionally, there were excellent patient reported outcomes and a low complication rate following the use of allograft for MPFL reconstruction.
Topics: Humans; Male; Female; Young Adult; Adult; Patellar Dislocation; Patellofemoral Joint; Joint Instability; Ligaments, Articular; Allografts
PubMed: 37979146
DOI: No ID Found -
The Knee Dec 2023Trochlear dysplasia is a condition in which the femoral trochlea has an abnormal shape and function. Trochleoplasty aims to change the shape of the trochlea in order to... (Meta-Analysis)
Meta-Analysis Review
Sulcus deepening trochleoplasty versus bereiter trochleoplasty for high grade trochlear dysplasia: A systematic review and meta-analysis for clinical outcome and recurrent instability.
BACKGROUND
Trochlear dysplasia is a condition in which the femoral trochlea has an abnormal shape and function. Trochleoplasty aims to change the shape of the trochlea in order to stabilize an unstable patella. This study compared clinical outcomes and recurrent instability after surgery between sulcus deepening trochleoplasty (Lyon) and Bereiter trochleoplasty in patients with high-grade trochlear dysplasia.
METHODS
We conducted a meta-analysis comparing Bereiter and Lyon trochleoplasty based on PRISMA guidelines regarding clinical outcome and recurrent instability for high-grade trochlear dysplasia. Searching on five databases, we found 11 eligible studies with a total of 520 subjects to be analysed. Studies were qualitatively and quantitatively evaluated using Review Manager 5.4 or equivalent.
RESULTS
Both techniques showed no differences in sulcus angle, return-to-sport rate, and satisfactory rate. The IKDC and Kujala scores showed good outcomes but were not significantly different. IKDC score was not different after analysis between Bereiter and Lyon techniques. The pooled improvement of IKDC score on both subgroups was 24.39 (95% CI 21.14-27.65). A pooled analysis of 10 studies found that the Kujala score did not differ between groups with Bereiter and Lyon techniques. The total pooled mean difference of both groups was 25.87 (95% CI 21.70-30.05).
CONCLUSION
None of the techniques analysed highlighted an absolute superiority. Clinical relevance showed both techniques have good clinical outcomes, fewer complications, and recurrent instability for high-grade trochlear dysplasia.
Topics: Humans; Patellar Dislocation; Knee Joint; Femur; Patella; Joint Instability; Patellofemoral Joint
PubMed: 37925805
DOI: 10.1016/j.knee.2023.10.001