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Arthroscopy : the Journal of... May 2021To examine the indications and outcomes of medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tubercle osteotomy (TTO) in treating recurrent or...
Tibial Tubercle Osteotomy May Not Provide Additional Benefit in Treating Patellar Dislocation With Increased Tibial Tuberosity-Trochlear Groove Distance: A Systematic Review.
PURPOSE
To examine the indications and outcomes of medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tubercle osteotomy (TTO) in treating recurrent or habitual patellar dislocation with an increased tibial tuberosity-trochlear groove (TT-TG) distance.
METHODS
We performed a literature search of the established medical databases Cochrane Central, PubMed-MEDLINE, EMBASE, and Web of Science. The inclusion criteria were as follows: skeletally mature patients with recurrent or habitual patellar dislocation and an increased TT-TG distance, treatment with MPFLR combined with a TTO procedure or isolated MPFLR, and reporting of clinical outcomes and complications. Each study was assessed for quality and the level of evidence. The general characteristics, indications, surgical techniques, TT-TG distance, clinical results, imaging evaluation findings, and complications of each study were recorded.
RESULTS
Nine studies consisting of 288 knees met the inclusion criteria. The average Coleman score was 71.56 (range, 55-83). The threshold for an increased TT-TG distance ranged from 16 to 20 mm in the included studies. Similar good postoperative outcomes were reported in patients with an increased TT-TG distance treated with MPFLR with versus without a TTO procedure. The mean postoperative Lysholm score ranged from 75.0 to 94.7 (I = 87.6%) in the isolated MPFLR group and from 85.0 to 87.6 (I = 16.3%) in the TTO-with-MPFLR group. Similar postoperative congruence angles were reported in both groups. The postoperative redislocation rate ranged from 0% to 4.2% in the TTO-with-MPFLR group, and no redislocation was found in the isolated MPFLR group. The postoperative apprehension sign was only reported in isolated MPFLR patients.
CONCLUSIONS
The outcomes of MPFLR with or without TTO to treat recurrent or habitual patellar dislocation with an increased TT-TG distance appeared similar. However, this study was limited by the considerable heterogeneity, variety of techniques, variety of TT-TG distances, and variability in patella alta and trochlear dysplasia among the included studies.
LEVEL OF EVIDENCE
Level IV, systematic review of Level II to IV studies.
Topics: Adolescent; Adult; Humans; Male; Osteotomy; Patellar Dislocation; Postoperative Complications; Postoperative Period; Tibia; Treatment Outcome; Young Adult
PubMed: 33359817
DOI: 10.1016/j.arthro.2020.12.210 -
Journal of Sport and Health Science Jan 2022The present study aimed to systematically review and compare 2 femoral autograft fixation techniques, namely, interference screws and suture anchors, for isolated medial... (Review)
Review
PURPOSE
The present study aimed to systematically review and compare 2 femoral autograft fixation techniques, namely, interference screws and suture anchors, for isolated medial patellofemoral ligament reconstruction in patients with recurrent patellofemoral instability at mid- to long-term follow-up.
METHODS
A literature search was performed in September 2020. All studies reporting the outcomes of primary isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability were considered for inclusion. Only studies reporting the type of femoral autograft fixation under examination were considered. Studies reporting data from patients with elevated tibial tuberosity-tibial groove, patella alta, and/or Dejour's trochlear dysplasia types C and D, were not included. Only articles reporting data with a minimum follow-up period of 18 months were considered.
RESULTS
Data from 19 studies (615 patients) were retrieved. The overall age was 24.4 ± 6.7 years (mean ± SD). The mean follow-up was 46.5 ± 20.9 months. There were 76 patients in the anchor group and 539 in the screw group. Comparability was found with regard to age and follow-up duration between the 2 study groups. There was comparability between the Kujala, Lysholm, and Tegner scores at baseline. At the last follow-up, no worthy differences were found in terms of mean Kujala (+2.1%; p = 0.04), Lysholm (+1.7%; p = 0.05), and Tegner (+15.8%; p = 0.05) scores. Although complications occurred almost exclusively in the screw cohort, no statistically significant difference was found.
CONCLUSION
Femoral autograft fixation through interference screws or suture anchors report similar clinical scores and rate of apprehension test, persistent joint instability, re-dislocations, and revisions. These results must be interpreted within the limitations of the present study.
Topics: Adolescent; Adult; Bone Screws; Humans; Ligaments, Articular; Patellar Dislocation; Patellofemoral Joint; Suture Anchors; Young Adult
PubMed: 33259964
DOI: 10.1016/j.jshs.2020.11.011 -
Journal of Orthopaedic Surgery and... Nov 2020The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart...
BACKGROUND
The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart stability to the patellofemoral joint. The anatomy and biomechanical characteristics of the MPFL have been well described but little is known about the MPTL and MPML. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, patellar and quadriceps tendons, allografts and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident.
METHODS
A systematic review of the literature was conducted using PRISMA guidelines. Inclusion criteria were articles that reported clinical outcomes of combined reconstruction of MPTL and MPFL. The methodological quality of the articles was determined using the modified Coleman Methodology Score (CMS).
RESULTS
Nine articles were included, reporting the clinical outcomes of 197 operated knees. The surgical procedures described include hamstrings grafting and transfer of the medial patellar and quadriceps tendons with or without bony procedures to reconstruct the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved. The median CMS is 70.6 ± 14.4 (range 38 to 84).
CONCLUSION
Different techniques are reported, and outcomes are good with low rates of recurrence. The quality of the articles is variable, ranging from low to high. Appropriately powered randomized controlled trials are needed to better understand what the adequate indications for surgery in patients with patellar instability and clinical outcomes are. Combined reconstruction of MPFL and MPTL leads to favourable clinical outcomes, supporting its role as a valid surgical procedure for patellar stabilization.
Topics: Female; Humans; Joint Instability; Ligaments, Articular; Male; Orthopedic Procedures; Patella; Patellar Dislocation; Patellofemoral Joint; Plastic Surgery Procedures; Tibia; Treatment Outcome
PubMed: 33183310
DOI: 10.1186/s13018-020-02072-z -
Arthroscopy, Sports Medicine, and... Oct 2020To highlight the indications and outcomes for sulcus-deepening trochleoplasty, when used as an isolated procedure as well as in combination with other stabilization... (Review)
Review
PURPOSE
To highlight the indications and outcomes for sulcus-deepening trochleoplasty, when used as an isolated procedure as well as in combination with other stabilization techniques for patellar instability.
METHODS
We performed a systematic review focused on outcomes and complications following trochleoplasty performed either as an isolated procedure or in combination with other procedures to address patellar instability. Inclusion criteria included studies in English that reported on outcomes following primary open trochleoplasty, including Kujala scores and recurrent instability or dislocation events.
RESULTS
Twelve papers including 702 patients who underwent sulcus-deepening trochleoplasty were included. A total of 504 patients underwent isolated sulcus-deepening trochleoplasty, whereas 198 patients underwent trochleoplasty in combination with 1 or more additional stabilization procedures. In total, 67% of patients were female compared with 33% male. The procedure was done was a primary surgical intervention 74% of the time. Postoperative Kujala scores for isolated trochleoplasty ranged from 80 to 92, whereas those for combined stabilization procedures ranged from 76 to 95. The dislocation rate among the studies ranged from 0 to 8%. There was a persistent J-sign in 0 to 12% of treated knees among all studies, and a persistent apprehension test in 0 to 29% of treated knees. Return to play ranged from 65% to 83% in studies in which this was reported as an outcome.
CONCLUSIONS
Sulcus-deepening trochleoplasty performed for recurrent patellar instability in the setting of trochlear dysplasia results in improved Kujala scores and a low redislocation rate, when performed as an isolated procedure or in combination with other stabilization procedures. Greater-level evidence is needed to better evaluate the overall efficacy of this procedure in addressing patellar instability.
LEVEL OF EVIDENCE
Level of Evidence, IV; Systematic review of level III and IV studies.
PubMed: 33135008
DOI: 10.1016/j.asmr.2020.06.009 -
The Surgeon : Journal of the Royal... Oct 2021The knowledge of the anatomy and biomechanics of patellar stabilizers is mandatory to achieve good clinical results with surgical reconstructive procedures. Few articles... (Review)
Review
BACKGROUND
The knowledge of the anatomy and biomechanics of patellar stabilizers is mandatory to achieve good clinical results with surgical reconstructive procedures. Few articles provide clear anatomical and biomechanical picture of medial patello-tibial ligament (MPTL).
METHODS
After a systematic review of the literature we selected in vivo or ex vivo studies providing anatomical or biomechanical measurements. We included 7 studies about MPTL anatomy for a total of 96 knees and 4 biomechanical studies.
RESULTS
The MPTL is a true ligament and important component of the medial patellar stabilizers, together with the medial patello-femoral ligament (MPFL) and medial patello-meniscal ligament. The contribution of MPTL on restriction forces of the patello-femoral joint is still unclear. Quadriceps, patellar, semitendinous and gracilis tendons are adequate grafts for surgical MPTL reconstruction.
CONCLUSIONS
MPTL is a well defined anathomical structure and histologically can be considered a ligament. It plays an important role in patellar stability especially it has a main role on patellar rotation and tilt instead on shift.
Topics: Biomechanical Phenomena; Humans; Joint Instability; Ligaments, Articular; Patella; Patellar Dislocation; Plastic Surgery Procedures
PubMed: 33121878
DOI: 10.1016/j.surge.2020.09.005 -
Orthopaedic Journal of Sports Medicine Sep 2020Whether surgical or nonsurgical management is more appropriate for primary patellar dislocations (PPDs) in adolescents (younger than 18 years) remains controversial. (Review)
Review
BACKGROUND
Whether surgical or nonsurgical management is more appropriate for primary patellar dislocations (PPDs) in adolescents (younger than 18 years) remains controversial.
PURPOSE
To compare the clinical outcomes of surgical versus nonsurgical treatment for adolescents and children with PPDs.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
There were 2 reviewers who independently searched the PubMed, Embase, Ovid, and Cochrane databases for English-language studies of randomized controlled trials (RCTs), quasi-RCTs, and observational studies comparing surgical with nonsurgical treatment for PPDs. The primary outcomes were redislocations, the Kujala score, and the Knee injury and Osteoarthritis Outcome Score (KOOS), and the secondary outcome was subsequent surgery.
RESULTS
A total of 6 studies were included in our systematic review and meta-analysis. Among patients younger than 18 years, surgery was associated with a lower redislocation rate compared with nonsurgical treatment within 5 years of treatment (risk ratio [RR], 0.58 [95% CI, 0.37-0.91]; = .02; = 47%) but not beyond 5 years (RR, 0.80 [95% CI, 0.59-1.07]; = .14; = 34%). However, surgery resulted in worse Kujala and KOOS scores compared with nonsurgical treatment. Yet, the treatment difference between the 2 groups tended to decrease over time.
CONCLUSION
The available evidence suggests that for adolescents with PPDs, surgery was superior to nonsurgical treatment in the short term to reduce the redislocation rate but resulted in poorer outcomes of knee function based on the Kujala and KOOS scores. However, the superiority of either surgical or nonsurgical treatment in adolescents did not appear to persist in the long term.
PubMed: 33015209
DOI: 10.1177/2325967120946446 -
The American Journal of Sports Medicine Mar 2021Medial patellofemoral ligament (MPFL) reconstruction is being performed more frequently in athletes experiencing recurrent patellar instability.
BACKGROUND
Medial patellofemoral ligament (MPFL) reconstruction is being performed more frequently in athletes experiencing recurrent patellar instability.
PURPOSE/HYPOTHESIS
The purpose was to systematically review the evidence in the orthopaedic sports medicine literature to determine both the rate and timing of return to play after MPFL reconstruction and the rate of further patellar instability. Our hypothesis was that there would be a high rate of return to play after MPFL reconstruction.
STUDY DESIGN
Systematic review.
METHODS
A systematic literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which utilized EMBASE, MEDLINE, and the Cochrane Library databases. Inclusion criteria for literature included clinical studies reporting on return to play after MPFL reconstruction. Rate of return to play, level of return, timing of return, rate of recurrent instability, and patient-reported outcomes were evaluated. Statistical analysis was performed using SPSS.
RESULTS
Our review found 27 studies including 1278 patients meeting our inclusion criteria. The majority of patients were women (58%), and the total group had a mean age of 22.0 years and a mean follow-up of 39.3 months. The overall rate of return to play was 85.1%, with 68.3% returning to the same level of play. The average time to return to play was 7.0 months postoperatively. The rate of recurrent instability events following reconstruction was 5.4%. There was an improvement in both mean visual analog scale, pain scores (preoperative: 4.3, postoperative: 1.6) and Tegner activity scores (preoperative: 4.8, postoperative: 5.5).
CONCLUSION
The overall rate of return to play was high after MPFL reconstruction for the treatment of recurrent patellar instability. However, a relatively high percentage of those patients were unable to return to their preoperative level of sport. Additionally, there was a moderate time taken to return to play, at approximately 7 months after the procedure.
Topics: Adult; Female; Humans; Joint Instability; Knee Joint; Ligaments, Articular; Male; Patellar Dislocation; Patellofemoral Joint; Return to Sport; Young Adult
PubMed: 32866030
DOI: 10.1177/0363546520947044 -
A Word of Caution for Future Studies in Patellofemoral Pain: A Systematic Review With Meta-analysis.The American Journal of Sports Medicine Feb 2021Patellar maltracking is widely accepted as an underlying mechanism of patellofemoral pain. However, methodological differences in the literature hinder our ability to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patellar maltracking is widely accepted as an underlying mechanism of patellofemoral pain. However, methodological differences in the literature hinder our ability to generate a universal quantitative definition of pathological patellofemoral kinematics (patellar maltracking) in patellofemoral pain, leaving us unable to determine the cause of patellofemoral pain.
PURPOSE
To systematically review the literature to provide evidence regarding the influence of confounding variables on patellofemoral kinematics.
STUDY DESIGN
Systematic review and random effects meta-analysis of control-case studies.
METHODS
A literature search of case-control studies that evaluated patellofemoral kinematics at or near full extension and were written in English was conducted using Embase, PubMed, Scopus, and Web of Science up to September 2019. Cases were defined as patients with patellofemoral pain. Studies were eliminated if they lacked quantitative findings; had a primary aim to assess therapy efficacy; or included participants with osteoarthritis and/or previous trauma, pathology, or surgery. A quality assessment checklist was employed to evaluate each study. Meta-analyses were conducted to determine the influence of confounding variables on measures of patellofemoral kinematics.
RESULTS
Forty studies met the selection criteria, with quality scores ranging from 13% to 81%. Patient characteristics, data acquisition, and measurement methods were the primary sources of methodological variability. Active quadriceps significantly increased lateral shift (standardized mean difference [SMD] = 0.33; = .0102) and lateral tilt (SMD = 0.43; = .006) maltracking. Individuals with pain secondary to dislocation had greater effect sizes for lateral maltracking than had those with isolated patellofemoral pain (ΔSMD = 0.71, = .0071; ΔSMD = 1.38, = .0055).
CONCLUSION
This review exposed large methodological variability across the literature, which not only hinders the generalization of results, but ultimately mitigates our understanding of the underlying mechanism of patellofemoral pain. Although our meta-analyses support the diagnostic value of maltracking in patellofemoral pain, the numerous distinct methods for measuring maltracking and the limited control for cofounding variables across the literature prohibit defining a single quantitative profile. Compliance with specific standards for anatomic and outcome measures must be addressed by the scientific and clinical community to establish methodological uniformity in this field.
Topics: Biomechanical Phenomena; Case-Control Studies; Humans; Joint Dislocations; Patella; Patellofemoral Joint; Patellofemoral Pain Syndrome; Quadriceps Muscle
PubMed: 32816535
DOI: 10.1177/0363546520926448 -
Knee Surgery & Related Research Aug 2019The purpose of this study is to review the use of an allograft or autograft in medial patellofemoral ligament (MPFL) reconstruction. (Review)
Review
PURPOSES
The purpose of this study is to review the use of an allograft or autograft in medial patellofemoral ligament (MPFL) reconstruction.
MATERIALS AND METHODS
Various electronic databases were searched for relevant articles published from January 2000 to September 2017 that evaluated clinical outcomes of MPFL reconstruction using an autograft or allograft. Data search, extraction, analysis, and quality assessments were performed based on Cochrane Collaboration guidelines.
RESULTS
The study of 21 autografts and one allograft was included in this review. Although direct comparative studies were unavailable, the Kujala score and subjective results were reported in the majority of these studies. While the use of an autograft for MPFL reconstruction yielded satisfactory clinical outcomes with few perioperative complications, no new outcome has been drawn from the use of allografts.
CONCLUSIONS
Although many studies have shown favorable clinical results for MPFL reconstruction using an autograft, the clinical results of MPFL reconstruction using an allograft have not yet been sufficient to achieve meaningful clinical results due to low levels of evidence. Direct comparisons were not conducted because there were very few studies on allografts; thus, further research in this area should be performed in the future.
PubMed: 32660535
DOI: 10.1186/s43019-019-0008-0 -
Knee Surgery, Sports Traumatology,... Apr 2021To assess the different surgical techniques and their outcomes following tibial tubercle transfer (TTT) in patients with patellar maltracking. (Meta-Analysis)
Meta-Analysis
PURPOSE
To assess the different surgical techniques and their outcomes following tibial tubercle transfer (TTT) in patients with patellar maltracking.
METHODS
A systematic search of the literature was performed in PubMed, EMBASE and Cochrane Library. Studies reporting patient-reported outcome measures (PROMs) or clinical outcome following: TTT in patients with patellar maltracking were included. Collected PROMs were Lysholm, Kujala, IKDC score, and VAS pain. Clinical outcome included reported clinical success, patient satisfaction, complications and removal of hardware (ROH). Overall pre-, post-operative and change scores were estimated using random-effects meta-analysis models. Results were reported as overall mean and per transfer direction.
RESULTS
A total of 26 studies and 761 patients (818 knees, mean age 35 years, mean follow-up 5.0 years) were included. In 73% of the studies, surgery was performed after failed conservative treatment. Transfer direction was anteromedial in 76% of all procedures. Overall Lysholm score improved from 61 to 91, Kujala from 52 to 85, IKDC from 53 to 81, and VAS from 6.2 to 2.5, respectively. Clinical success was reported in 79% of patients, and 80% of patients reported to have satisfactory results. Rates of complications and ROH were 13% and 29%, respectively.
CONCLUSIONS
TTT for management of patellar maltracking can lead to good results with clinically meaningful improvement, an overall clinical success of 79% and overall patient satisfaction of 80% when appreciating the underlying anatomic condition and using appropriate technique. The level of evidence was low, and large-scale prospective, comparative cohort studies with uniform outcome scales are needed to confirm these findings.
LEVEL OF EVIDENCE
IV.
Topics: Adult; Female; Humans; Joint Instability; Lysholm Knee Score; Male; Middle Aged; Osteotomy; Pain Measurement; Patella; Patellar Dislocation; Patellofemoral Joint; Patellofemoral Pain Syndrome; Patient Reported Outcome Measures; Postoperative Period; Tibia; Treatment Outcome; Young Adult
PubMed: 32594329
DOI: 10.1007/s00167-020-06114-1