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The American Journal of Sports Medicine Jul 2024Recent systematic reviews on the outcomes of sulcus-deepening trochleoplasty with adjuvant medial patellofemoral ligament (MPFL) reconstruction at a follow-up of 2 to 6...
BACKGROUND
Recent systematic reviews on the outcomes of sulcus-deepening trochleoplasty with adjuvant medial patellofemoral ligament (MPFL) reconstruction at a follow-up of 2 to 6 years have found that the procedure grants good clinical outcomes with low redislocation rates. However, there is a lack of evidence in the literature regarding mid- and long-term follow-ups.
PURPOSE
To evaluate the radiographic and clinical outcomes of thick-flap sulcus-deepening trochleoplasty with MPFL reconstruction at a minimum follow-up of 10 years to assess the signs of patellofemoral arthritis, incidence of recurrent dislocation, and grade of patient satisfaction.
STUDY DESIGN
Case series; Level of evidence, 4.
METHODS
The authors evaluated a retrospective series of 43 patients (48 knees) who underwent sulcus-deepening trochleoplasty between 2003 and 2013. All patients underwent thick-flap sulcus-deepening trochleoplasty with additional MPFL reconstruction. All patients were assessed at a minimum follow-up of 10 years by an independent clinician who noted any patellar redislocation or reoperations in the operated knee and collected the International Knee Documentation Committee (IKDC), Kujala, and satisfaction scores. Furthermore, a radiographic examination was performed to assess patellar height using the Caton-Deschamps index and patellofemoral arthritis using the Iwano classification.
RESULTS
At a mean follow-up of 14.8 ± 2.1 years (range, 10-20 years), 4 patients (4 knees) were lost to follow-up (8.3%). The satisfaction, Kujala, and IKDC scores were 8.2 ± 1.6, 77.5 ± 14.4, and 65.7 ± 13.5, respectively. Only 1 patient reported a traumatic patellar dislocation (2%). Radiographs at the final follow-up were available for 34 knees, which revealed Iwano grade 1 in 14 knees (41%), Iwano grade 2 in 7 knees (21%), and no patellofemoral arthritis in 13 knees (38%).
CONCLUSION
Sulcus-deepening trochleoplasty with MPFL reconstruction provides satisfactory results and prevents patellar redislocations with no or minimal patellofemoral arthritis.
Topics: Humans; Retrospective Studies; Adult; Male; Female; Patellofemoral Joint; Young Adult; Patient Satisfaction; Adolescent; Patellar Dislocation; Follow-Up Studies; Ligaments, Articular; Treatment Outcome; Middle Aged; Plastic Surgery Procedures; Radiography
PubMed: 38828633
DOI: 10.1177/03635465241253265 -
Japanese Journal of Radiology May 2024This study aims to evaluate the application value of the tibial tubercle-trochlear groove distance (TT-TG distance) and tibial tubercle-midepicondyle distance (TT-ME...
PURPOSE
This study aims to evaluate the application value of the tibial tubercle-trochlear groove distance (TT-TG distance) and tibial tubercle-midepicondyle distance (TT-ME distance) on CT images in patellofemoral instability, and further investigate the association between knee joint rotation angles and patellofemoral instability.
METHODS
We retrospectively analyzed CT image data of 59 patients with patellar dislocation (case group) and 39 normal knee joints (control group). We measured the TT-TG distance, TT-ME distance, and knee joint rotation angle (KJRA) of both groups, and the related indicators were analyzed using single-factor/multi-factor binary logistic stepwise regression analysis. Two senior radiologists were assigned to assess the inter-rater reliability. Interclass correlation coefficients (ICC) were calculated. Finally, we used receiver operating characteristic (ROC) curves to compare the diagnostic efficiency of these indicators in patellofemoral instability.
RESULTS
The results found significant differences between both groups in terms of TT-TG distance, TT-ME distance, KJRA angle, age, location, and gender (P < 0.05). In terms of inter-rater reliability, TT-TG distance and TT-ME distance ratios showed an excellent correlation between observers (TT-TG inter-rater ICC 0.969, TT-ME inter-rater ICC 0.955). Univariate logistic regression analysis indicated that except for location and gender, all other factors significantly affected patellofemoral instability (P < 0.05). The multivariate logistic regression analysis revealed that the TT-ME distance, age, and KJRA angle were statistically significant factors related to patellofemoral instability, with TT-ME distance being a risk factor for patellofemoral instability (OR value 1.572, P value 0.000). Moreover, the ROC curve analysis demonstrated that the diagnostic capability of the TT-ME distance for detecting patellofemoral instability was higher than that of the TT-TG distance and KJRA (AUC were 0.912, 0.851, and 0.735, respectively).
CONCLUSION
The TT-ME distance, age, and knee joint rotation angle are factors that affect patellofemoral instability. The TT-ME distance has better diagnostic efficiency for patellofemoral instability compared to the TT-TG distance and knee joint rotation angle.
PubMed: 38819693
DOI: 10.1007/s11604-024-01601-8 -
Journal of ISAKOS : Joint Disorders &... May 2024Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time... (Review)
Review
Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation, and patellar height. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.
PubMed: 38795864
DOI: 10.1016/j.jisako.2024.05.013 -
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 -
Knee Surgery, Sports Traumatology,... May 2024We aimed to establish patient-reported outcome measure (PROM) reference data for a cohort of patients with prior patellar dislocation without previous knee surgery.
Adolescents with prior patellar dislocation report affected quality of life and function, as measured using the Banff Patella Instability Instrument, Kujala and EQ-5D-5L index scores.
PURPOSE
We aimed to establish patient-reported outcome measure (PROM) reference data for a cohort of patients with prior patellar dislocation without previous knee surgery.
METHODS
All inhabitants of the Faroe Islands aged 15-19 years were sent an online survey via secure email to establish a national cohort. They were asked to answer questions regarding demographics, whether they had prior patellar dislocation and to complete the PROMs: the Banff Patella Instability Instrument (BPII), Kujala, Marx activity and EQ-5D-5L questionnaires. Participants who had undergone knee surgery were excluded. Participants who had prior patellar dislocation underwent radiographic examinations to diagnose trochlear dysplasia. The study included three cohorts: the general population, prior patellar dislocation and prior patellar dislocation and trochlear dysplasia cohorts.
RESULTS
Of the 3749 individuals contacted, 1119 completed the survey and responded to at least one PROM. Of these, 102 reported a history of patellar dislocation and 57 of them had trochlear dysplasia. All PROMs, except the Marx score, reflected a worse quality of life and function after patellar dislocation than in the general population cohort; this was most pronounced in the BPII. The percentage of people experiencing problems in EQ-5D-5L dimensions was higher in the patellar dislocation and trochlear dysplasia cohorts than in the general population cohort in all EQ-5D-5L domains, except anxiety/depression.
CONCLUSION
Adolescents who had patellar dislocation reported reduced quality of life and function according to the BPII, Kujala and EQ-5D-5L index values, as well as all EQ-5D-5L domains, except for anxiety/depression. However, their activity levels remained high.
LEVEL OF EVIDENCE
Level III.
PubMed: 38769842
DOI: 10.1002/ksa.12270 -
Journal of ISAKOS : Joint Disorders &... May 2024We report the case of a 26-year-old woman who presented with a profound gait disturbance and total disability following a medial patellofemoral ligament (MPFL)...
We report the case of a 26-year-old woman who presented with a profound gait disturbance and total disability following a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. It is common knowledge that patellar instability is associated with multiple risk factors, including but not limited to loss of the MPFL, trochlear dysplasia, patella alta, an abnormally placed tibial tuberosity on the tibia, quadriceps contracture, genu valgum, excess of femoral anteversion, excess of external tibial torsion, and foot pronation. Since the relative importance of each is unknown, it is imperative that pre-operative evaluation considers these. Two additional surgeries failed to improve her severe disability. Subsequent evaluation, 8 years after her initial MPFL reconstruction, revealed the presence of an excess of external tibial torsion and genu valgum. Complete resolution of disability resulted following tibial osteotomy, suggesting the importance of torsional deformity contributing to patellofemoral instability. Gait disturbance is an unrecognised complication after MPFL reconstruction.
PubMed: 38768814
DOI: 10.1016/j.jisako.2024.05.010 -
Seminars in Musculoskeletal Radiology Jun 2024Patellofemoral instability results from impaired engagement of the patella in the trochlear groove at the start of flexion and may lead to pain and lateral patellar... (Review)
Review
Patellofemoral instability results from impaired engagement of the patella in the trochlear groove at the start of flexion and may lead to pain and lateral patellar dislocation. It occurs most frequently in adolescents and young adults during sporting activities. Trochlear dysplasia, patella alta, and excessive lateralization of the tibial tuberosity are the most common risk factors for patellar instability. The main role of imaging is to depict and assess these anatomical factors and highlight features indicating previous lateral dislocation of the patella.
Topics: Humans; Joint Instability; Patellofemoral Joint; Patella; Patellar Dislocation; Magnetic Resonance Imaging; Risk Factors
PubMed: 38768591
DOI: 10.1055/s-0044-1785538 -
Cureus Apr 2024Purpose Understanding the relevant risk factors for patellar instability and the clinical and radiographic tests necessary to determine optimal treatment. This case...
Purpose Understanding the relevant risk factors for patellar instability and the clinical and radiographic tests necessary to determine optimal treatment. This case series intends to evaluate arthroscopic indications in the treatment of patellar instability in children. Methods From 2013 to 2021, 33 patients (seven to 16 years of age) with 35 knees sustaining first-time dislocation with loose bodies, recurrent dislocation or subluxation, and habitual dislocation were arthroscopically operated on according to the flow chart. Periods of follow-up were two to 10 years (avg. 5.5 years). Follow-up assessment included the recurrence, complications (joint stiffness and excessive reduction), and the final function outcomes by using the Kujala score. Results Among 35 knees, there were two (5.7%) first dislocations, 30 (85.7%) recurrent dislocations, and three (8.6%) habitual dislocations, lateral release 27/35 (77.1%), medial reefing 23/35 (65.7%), reconstruction of the medial patellofemoral ligament (MPFL) 12/35 (34.3%). The major complication was a knee of extensive stiffness after medial reefing and lateral release. Recurrence was in 4/35 (11.4%) of knees, not correlated to lateral release (p=0.21), medial reefing, or reconstruction of MPFL (p=0.07); in about 23 knees of medial reefing, recurrence was significantly correlated to number of knots (p=0.045). The final functional results according to Kujala were 88-100 (avg. 95.5). Conclusions This study showed the role of arthroscopy in both medial reefing and reconstruction of MPFL in children by low recurrence rate and high Kujala score at final follow-up. There was no significant correlation between recurrence and the procedures as arthroscopic indications counted on the flow chart.
PubMed: 38765341
DOI: 10.7759/cureus.58437 -
BMC Musculoskeletal Disorders May 2024A variety of measurement methods and imaging modalities are in use to quantify the morphology of lateral femoral condyle (LFC), but the most reliable method remains...
BACKGROUND
A variety of measurement methods and imaging modalities are in use to quantify the morphology of lateral femoral condyle (LFC), but the most reliable method remains elusive in patients with lateral patellar dislocation (LPD). The purpose of this study was to determine the intra- and inter-observer reliability of different measurement methods for evaluating the morphology of LFC on different imaging modalities in patients with LPD.
METHODS
Seventy-three patients with LPD were included. Four parameters for quantifying the morphology of LFC were retrospectively measured by three observers on MRI, sagittal CT image, conventional radiograph (CR), and three-dimensional CT (3D-CT). The intra-class correlation coefficient was calculated to determine the intra- and inter-observer reliability. Bland-Altman analysis was conducted to identify the bias between observers.
RESULTS
The lateral femoral condyle index (LFCI) showed better intra- and inter-observer reliability on MRI and 3D-CT than on CR and sagittal CT images. The mean difference in the LFCI between observers was lowest on 3D-CT (0.047), higher on MRI (0.053), and highest on sagittal CT images (0.062). The LFCI was associated with the lateral femoral condyle ratio (ρ = 0.422, P = 0.022), lateral condyle index (r = 0.413, P = 0.037), and lateral femoral condyle distance (r = 0.459, P = 0.014). The LFCI could be reliably measured by MRI and 3D-CT.
CONCLUSION
The LFCI could be reliably measured by MRI and 3D-CT. The LFCI was associated with both the height and length of LFC and could serve as a comprehensive parameter for quantifying the morphology of LFC in patients with LPD.
Topics: Humans; Female; Male; Reproducibility of Results; Patellar Dislocation; Magnetic Resonance Imaging; Femur; Tomography, X-Ray Computed; Retrospective Studies; Young Adult; Adult; Imaging, Three-Dimensional; Adolescent; Observer Variation
PubMed: 38762738
DOI: 10.1186/s12891-024-07495-x -
Knee Surgery, Sports Traumatology,... May 2024The purpose of this study was to investigate whether double-level (femur + tibia) derotational osteotomy is superior to single-level femoral derotational osteotomy...
Surgical treatment for recurrent patellar dislocation with severe torsional deformities: Double-level derotational osteotomy may not have a clear advantage over single-level derotational osteotomy in improving clinical and radiological outcomes.
PURPOSE
The purpose of this study was to investigate whether double-level (femur + tibia) derotational osteotomy is superior to single-level femoral derotational osteotomy for recurrent patellar dislocation with severe femoral and tibial rotational deformities (femoral anteversion >30° and external tibial torsion >30°).
METHODS
Between January 2015 and June 2020, a total of 115 knees with recurrent patellar dislocation treated with combined medial patellofemoral ligament reconstruction (MPFL-R) and derotational osteotomies were evaluated after a minimum follow-up of 2 years. Among these cases, 15 knees that underwent double-level derotational osteotomy were included in the double-level group, which was propensity-matched in a 1:2 ratio to a single-level group of patients who underwent single-level femoral derotational osteotomy (30 knees). The clinical and radiological outcomes were evaluated and compared between the groups. Furthermore, the foot progression angle was measured preoperatively and 2 years after surgery.
RESULTS
The patient-specific variables did not differ significantly between the double- and the single-level groups after propensity score matching. The postoperative mean foot progression angle was significantly lower in the double-level group than in the single-level group (9° ± 8° vs. 15° ± 11°; p = 0.014); however, there were no statistically significant differences between the groups in terms of any other clinical and radiological assessments.
CONCLUSION
For patients with severe femoral and tibial torsional deformities (femoral anteversion >30° and external tibial torsion >30°), the double-level derotational osteotomy is superior to single-level osteotomy in maintaining normal foot progression angle, but it does not show an advantage in terms of patient-reported outcomes, radiological results and redislocation rate at minimum 2 years of follow-up. Furthermore, concomitant excessive external tibial torsion (>30°) did not have an adverse effect on clinical outcomes in patients who underwent derotational distal femoral osteotomy with MPFL-R due to excessive femoral anteversion.
LEVEL OF EVIDENCE
Level III.
PubMed: 38751078
DOI: 10.1002/ksa.12246