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Orthopaedic Journal of Sports Medicine Oct 2021Patients with recurrent lateral patellar dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL). (Review)
Review
BACKGROUND
Patients with recurrent lateral patellar dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL).
PURPOSE
To perform a systematic review to evaluate clinical outcomes and the risk of recurrent patellar dislocation after MPFL reconstruction (MPFLR) with autograft versus allograft.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
The authors conducted a search of PubMed, the Cochrane Library, and Embase to identify studies comparing outcomes of MPFLR with autograft versus allograft. The inclusion criteria were full-text studies that directly compared clinical outcomes and/or risk of recurrent patellar instability between patients undergoing MPFLR with autograft versus allograft. A quality assessment was performed using the modified Coleman Methodology Score, and risk-of-bias assessment was performed using the Risk Of Bias In Non-randomized Studies-of Interventions and the Cochrane Collaboration tools.
RESULTS
Seven studies (1 evidence level 2, 3 level 3, 3 level 4) that met inclusion criteria were identified and included a total of 150 patients who underwent MPFLR with autograft and 193 with MPFLR with allograft. One study found a significantly higher failure rate among patients with autograft, and another study found a trend toward a significantly higher failure rate among patients with autograft. One study demonstrated no significant difference between postoperative tibial tubercle-trochlear groove distance (measured on magnetic resonance imaging scans) in failed versus successful grafts. One study found that patellar tilt angle improved significantly from preoperatively to postoperatively ( < .001) but there was no difference between the groups. Kujala scores significantly improved for both autograft and allograft groups across studies. Two studies found significant differences in postoperative Kujala scores between the 2 groups, 1 of which found better scores in the allograft group ( = .0032) and another in which scores were better in the autograft group ( = .02).
CONCLUSION
Patients undergoing MPFLR with either autograft or allograft can expect to experience improvement in clinical outcomes. Subjective outcomes improved to a similar degree in both groups. Graft failure was more frequently observed in patients with autograft. Allograft may be a better option for MPFLR owing to lower failure rate.
PubMed: 34692883
DOI: 10.1177/23259671211046639 -
Orthopaedic Journal of Sports Medicine Sep 2021Medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and nonoperative treatment are important treatments for patients with patellar dislocation. However,... (Review)
Review
BACKGROUND
Medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and nonoperative treatment are important treatments for patients with patellar dislocation. However, it is unclear which treatment leads to better outcomes.
PURPOSE
To determine the efficacy and safety of the 3 treatments in the treatment of patellar dislocation and compare the effect of MPFL reconstruction with MPFL repair, MPFL reconstruction with nonoperative treatment, and MPFL repair with nonoperative treatment.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
The PubMed, Web of Science, Cochrane Library, Embase, CNKI (China National Knowledge Infrastructure), and Wanfang databases were searched from inception to December 2020. Included were clinical studies that described the efficacy and safety of 2 of the 3 treatments, studies directly comparing the clinical effects of the 2 operative techniques, or studies comparing the effects of reconstruction or repair with nonoperative treatment. Two reviewers independently extracted data and assessed the quality of the included studies with the Cochrane risk-of-bias tools. The outcomes evaluated were postoperative redislocation rate, revision rate, complications, and Kujala score. We used traditional direct pairwise meta-analysis as well as network meta-analysis for comprehensive efficacy of all 3 treatment measures.
RESULTS
Twelve studies were included: 5 compared MPFL reconstruction with MPFL repair, 2 compared MPFL reconstruction with nonoperative treatment, and 5 compared MPFL repair with nonoperative treatment. The risk of bias was serious in 4, moderate in 4 and low in 4 articles. MPFL reconstruction led to significantly reduced redislocation and improved Kujala scores compared with MPFL repair and nonoperative treatment. MPFL repair led to reduced redislocation rates compared with nonoperative treatment but did not show an obvious benefit in primary dislocations. There was no significant difference among the 3 treatments in terms of revision rate and incidence of complications, although we found that treatment-related complications were least likely to occur in nonoperative treatment.
CONCLUSION
The results of this review indicate that MPFL reconstruction decreases recurrent dislocation compared with MPFL repair or nonoperative treatment, but it has a higher possibility of complications. MPFL repair resulted in less postoperative redislocation than nonoperative treatment but did not show an obvious benefit in primary dislocation.
PubMed: 34604425
DOI: 10.1177/23259671211026624 -
Knee Surgery, Sports Traumatology,... May 2022Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature... (Review)
Review
Good clinical outcomes after patellar cartilage repair with no evidence for inferior results in complex cases with the need for additional patellofemoral realignment procedures: a systematic review.
PURPOSE
Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature analysed clinical results after regenerative cartilage repair of the patella with a special focus on the assessment and treatment of existing patellofemoral malalignment.
METHODS
A systematic review was conducted to identify articles reporting clinical results after cartilage regenerative surgeries of the patella using the PubMed and Scopus database. The extracted data included patient-reported outcome measures (PROMS) and whether cartilage repair was performed alone or in combination with concomitant surgeries of underlying patellofemoral co-pathologies. In cases of isolated cartilage repair, specific exclusion criteria regarding underlying co-pathologies were screened. In cases of concomitant surgeries, the type of surgeries and their specific indications were extracted.
RESULTS
A total of 35 original articles were included out of which 27 (77%) were cohort studies with level IV evidence. The most frequently used technique for cartilage restoration of the patella was autologous chondrocyte implantation (ACI). Results after isolated cartilage repair alone were reported by 15 (43%) studies. Of those studies, 9 (60%) excluded patients with underlying patellofemoral malalignment a priori and 6 (40%) did not analyse underlying co-pathologies at all. Among the studies including combined surgeries, the most frequently reported concomitant procedures were release of the lateral retinaculum, reconstruction of the medial patellofemoral ligament (MPFL), and osteotomy of the tibial tubercle. In summary, these studies showed lower preoperative PROMS but similar final PROMS in comparison with the studies reporting on isolated cartilage repair. The most frequently used PROMS were the IKDC-, Lysholm- and the Modified Cincinnati Score.
CONCLUSION
This comprehensive literature review demonstrated good clinical outcomes after patellar cartilage repair with no evidence of minor results even in complex cases with the need for additional patellofemoral realignment procedures. However, a meaningful statistical comparison between isolated patellar cartilage repair and combined co-procedures is not possible due to very heterogeneous patient cohorts and a lack of analysis of specific subgroups in recent literature.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Joint Instability; Knee Joint; Ligaments, Articular; Osteotomy; Patella; Patellar Dislocation; Patellofemoral Joint
PubMed: 34510221
DOI: 10.1007/s00167-021-06728-z -
Orthopaedics & Traumatology, Surgery &... Nov 2021Trochleoplasty is an effective patellar stabilization procedure; however, it is associated with a risk of complications that cannot be ignored. Prior systematic reviews... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Trochleoplasty is an effective patellar stabilization procedure; however, it is associated with a risk of complications that cannot be ignored. Prior systematic reviews on this topic did not include more recent studies reporting important outcomes, particularly the long-term results of lateral elevation trochleoplasty. This led us to carry out a new meta-analysis of the various trochleoplasty procedures to specify: (1) the recurrence rate of patellofemoral dislocation; (2) the complication rates and; (3) the clinical outcomes.
PATIENTS AND METHODS
Studies reporting complications and clinical outcomes of trochleoplasty, whether or not it was combined with other procedures for patellofemoral instability, were identified in the MEDLINE, Embase, Scopus, Cochrane Library, Web of Science databases and by searching the grey literature. The primary endpoint was the recurrence of patellofemoral dislocation while the secondary endpoints were objective patellofemoral instability without dislocation, stiffness, patellofemoral osteoarthritis, subsequent surgeries and various clinical outcome scores. The results were combined in a random-effects model (weighing factor: inverse variance) when the heterogeneity was less than 80%.
RESULTS
Twenty-eight studies were included: 5 featured lateral elevation trochleoplasty, 10 about the Dejour deepening trochleoplasty, 12 about the Bereiter deepening trochleoplasty and 1 about the recession wedge trochleoplasty. A total of 1000 trochleoplasty procedures were done in 890 patients who had a follow-up of 1 to 25 years. There were 24 cases of recurrent dislocation (24/994 [2.4%]; this outcome was not reported for 6 trochleoplasties). The Dejour deepening trochleoplasty was the most effective with only 1 recurrence in 349 knees (0.28%). For the other complications, residual patellar instability without dislocation occurred in 82 of 754 knees (8% [95% CI: 3-14%]), patellofemoral osteoarthritis in 117 of 431 knees (27%), stiffness in 59 of 642 knees (7% [95% CI: 3-12%]) and the need for subsequent surgery in 151 of 904 knees (17%).
DISCUSSION
This study found a low recurrence rate for patellofemoral dislocation and residual instability. The incidence of stiffness, patellofemoral osteoarthritis and subsequent surgery remains high but differs greatly between studies. This meta-analysis showed a very large disparity between studies for most complications, which justifies the need for randomized and comparative studies to establish the role of trochleoplasty procedures in the treatment algorithm for patellar instability.
LEVEL OF EVIDENCE
IV; systematic review and meta-analysis.
Topics: Humans; Joint Instability; Osteoarthritis, Knee; Patella; Patellar Dislocation; Patellofemoral Joint
PubMed: 34365023
DOI: 10.1016/j.otsr.2021.103035 -
The American Journal of Sports Medicine Jul 2022Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues.
PURPOSE
To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability.
STUDY DESIGN
Systematic review and network meta-analysis; Level of evidence, 1.
METHODS
The literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability were included. Clinical outcomes included recurrent instability (including both dislocations and subluxations), redislocation, and Kujala score. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using the statistical software R. The treatment options were ranked using scores.
RESULTS
There were 13 RCTs with a total of 789 patients, all with a minimum follow-up of 24 months. There were 150 patients treated using MPFL reconstruction, 353 treated using MPFL repair, and 286 treated nonoperatively. Overall, MPFL reconstruction had the highest score (0.9967) and resulted in a significantly lower recurrence rate than did MPFL repair (odds ratio [OR], 0.42; 95% CI, 0.07-0.72) and nonoperative management (OR, 0.09; 95% CI, 0.03-0.32). In addition, MPFL repair resulted in a significantly lower recurrence rate than did nonoperative management (OR, 0.42; 95% CI, 0.25-0.70). MPFL reconstruction had the highest score (0.9651) and resulted in a significantly higher Kujala score than did nonoperative management (mean difference, 10.45; 95% CI, 0.41-20.49) but not MPFL repair (mean difference, 0.15; 95% CI, 0.03-0.68). Subgroup analysis revealed that MPFL reconstruction had the highest score for all outcomes in those with first-time dislocation.
CONCLUSION
The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.
Topics: Humans; Joint Dislocations; Joint Instability; Ligaments, Articular; Network Meta-Analysis; Patellar Dislocation; Patellofemoral Joint; Randomized Controlled Trials as Topic
PubMed: 34339311
DOI: 10.1177/03635465211020000 -
Physical Therapy in Sport : Official... Sep 2021Synthesize evidence on objectively quantified lower limb strength recovery in people treated surgically or non-surgically after patellar dislocation. (Review)
Review
OBJECTIVE
Synthesize evidence on objectively quantified lower limb strength recovery in people treated surgically or non-surgically after patellar dislocation.
METHODS
MEDLINE, EMBASE, Cochrane Library, SPORTDiscus, PEDro, AMED and CINAHL databases were last searched on July 30th, 2020 for randomized controlled trials and observational studies that objectively quantified lower limb strength in people (any age or sex) treated surgically or non-surgically after patellar dislocation.
RESULTS
24 studies were included (877 participants, median age 20.7). All assessed knee extension strength, 11 knee flexion strength, three hip abduction strength, two hip external rotation strength, and one hip flexion, extension, adduction, and internal rotation strength. One randomized controlled trial judged at high risk of bias and two cohort studies with methodological limitations compared lower limb strength recovery between surgically and non-surgically treated people, with conflicting findings. After surgery, median long-term (>8 months) knee extension strength was 82.5% (IQR 78.5-88.2; 13 studies) of the unaffected leg and knee flexion strength was 91.5% (IQR 90.7-96.9; five studies). After non-surgical treatment, median long-term knee extension strength was 86% (IQR 79.3-87.4; four studies) and mean flexion strength ranged from 95.2 to 96.7% (two studies). Mean hip strength was always >90% (two studies). Two redislocations during eccentric isokinetic knee testing and knee pain during isokinetic knee extension testing were reported as adverse events.
CONCLUSIONS
Available evidence indicates that after patellar dislocation, knee extension strength deficits in the affected limb are frequently observed and can persist long term, but this remains uncertain due to the limitations of relevant included studies. Whether lower limb strength recovery differs between people treated surgically and those treated non-surgically after patellar dislocation also remains uncertain.
TRIAL REGISTRATION
(PROSPERO CRD42019139533).
Topics: Adult; Exercise Therapy; Humans; Knee Joint; Lower Extremity; Patella; Range of Motion, Articular; Young Adult
PubMed: 34325188
DOI: 10.1016/j.ptsp.2021.06.003 -
Knee Surgery, Sports Traumatology,... Apr 2022The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar...
PURPOSE
The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability.
METHODS
Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size.
RESULTS
From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons.
CONCLUSION
The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO's for evaluating patellofemoral instability outcomes.
LEVEL OF EVIDENCE
Level III.
Topics: Female; Humans; Joint Instability; Ligaments, Articular; Male; Patellar Dislocation; Patellofemoral Joint; Patient Reported Outcome Measures; Prevalence
PubMed: 34132856
DOI: 10.1007/s00167-021-06625-5 -
European Journal of Orthopaedic Surgery... May 2022The primary aim of the study is to compare the patient outcome in medial patellofemoral ligament reconstruction (MPFLR) or MPFLR concurrent with trochleoplasty... (Review)
Review
Medial patellofemoral ligament reconstruction with and without trochleoplasty for patients with patella instability-correlation of trochlear dysplasia and patient outcome, classification and outcome measure in the past decade-a systematic review.
PURPOSE
The primary aim of the study is to compare the patient outcome in medial patellofemoral ligament reconstruction (MPFLR) or MPFLR concurrent with trochleoplasty (MPFLR + TP) and correlate it with the degree of trochlear dysplasia (TD). The secondary aim is to review TD classification, outcome measure, chronological and geographical trend of such studies in the past decade.
METHODS
A systemic review of the literature in the past decade on studies of patients with patella instability and underwent either a MPFLR or MPFLR + TP. The degree of TD with the patient outcome was correlated and compared between the 2 groups. The TD classification, outcome measures, chronological and geographical trends of these studies were documented.
RESULTS
There is no statistical difference in the overall improvement in the compared outcome scores between the 2 groups. However, the MPFLR studies reported a total of 16 re-dislocation in contrast to none in the MPFLR + TP studies. The 24 selected studies in the current review utilized different TD classification as well as outcome measures. A more homogeneous subgroup of 12 studies utilized Dejour classification as well as Kujala score that enabled comparison and showed no significant difference in outcome. The highest number of MPFLR publications was in 2019 and was from North and South Americas, Asia and Europe. The MPFLR + TP studies were from Europe during 2013 to 2017.
CONCLUSION
Though there is an overall improvement in post-operative outcomes scores with no statistical significance between MPFLR and MPFLR + TP, the documented re-dislocations in the MPFLR studies suggested an undetermined zone where the choice of procedure could result in a different outcome. The current review did not show correlation between the degree of TD with the patient outcome to provide a clear indication for either procedure according to the degree of TD. The diverse TD classifications and varied outcome measures indicated the need for standardization and consistency in documentation to guide the treating clinician in the choice of procedure. MPFLR was more commonly performed and studied than MPFLR + TP in the past decade.
Topics: Humans; Joint Dislocations; Joint Instability; Ligaments, Articular; Outcome Assessment, Health Care; Patella; Patellar Dislocation; Patellofemoral Joint
PubMed: 34120236
DOI: 10.1007/s00590-021-03030-z -
Orthopaedic Journal of Sports Medicine May 2021Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings... (Review)
Review
BACKGROUND
Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies.
PURPOSE
To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms "patellar instability," "patellar dislocation," "trochlear dysplasia," "radiographic measures," "computed tomography," and "magnetic resonance imaging." Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values.
RESULTS
A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle-trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance ( < .01), Insall-Salvati ratio ( = .01), and femoral sulcus angle ( = .02) were significantly different between the instability and control groups. Values for tibial tubercle-posterior cruciate ligament distance ( = .36) and Caton-Deschamps index ( = .09) were not significantly different between groups.
CONCLUSION
The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle-posterior cruciate ligament, and patellar tendon-trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.
PubMed: 34095324
DOI: 10.1177/2325967121993179 -
Children (Basel, Switzerland) May 2021This study aimed to review the data available in the current literature concerning the complications and recurrence of instability following medial patellofemoral...
BACKGROUND
This study aimed to review the data available in the current literature concerning the complications and recurrence of instability following medial patellofemoral ligament (MPFL) reconstruction for patellar instability in young and adolescent patients (those <20 years old).
METHODS
A systematic review was performed based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, EMBASE, and Cochrane databases. The terms "medial patellofemoral ligament" or "MPFL" and "reconstruction" and "young" or "adolescents" or "children" were used. The inclusion criteria for the literature review comprised studies that reported the complications and recurrences of instability in patients who had undergone MPFL reconstruction for patellar instability.
RESULTS
In all, 332 patients were included in the review, of which 195 were females (63.5%) and 112 were males (36.5%), and they totaled 352 treated knees. The mean age at the time of the surgery was 14.28 years, and the mean follow-up duration was 30.17 months. A total of 16 (4.5%) complications were reported: one (0.3%) patella fracture, one (0.3%) screw removal due to intolerance, one (0.3%) infection, five (1.4%) wound complications, six (1.7%) subluxations and two (0.6%) instances of post-operative stiffness. A total of 18 (5.1%) recurrences of patellar instability were recorded.
CONCLUSIONS
MPFL reconstruction in young patients can be considered an effective and safe treatment leading to clinical improvement in terms of recurrence of dislocation. No major complications related to the technique were reported, but a high level of research evidence is required to better evaluate the clinical results in a long-term follow-up.
PubMed: 34064244
DOI: 10.3390/children8060434