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Medicine Jul 2019To systematically review the efficacy of surgical versus nonsurgical treatment for acute patellar dislocation. (Meta-Analysis)
Meta-Analysis
BACKGROUND
To systematically review the efficacy of surgical versus nonsurgical treatment for acute patellar dislocation.
MATERIALS AND METHODS
PubMed, Cochrane, and Embase were searched up to February 12, 2019. After removing duplicates, preliminary screening, and reading the full texts, we finally selected 16 articles, including 11 randomized controlled trials and 5 cohort studies. The quality of the enrolled studies was evaluated by Jadad score or Newcastle-Ottawa scale. Meta-analyses were performed using odds ratio (OR) and standardized mean difference (SMD) as effect variables. The clinical parameters assessed included mean Kujala score, rate of redislocation, incidence of patellar subluxation, patient satisfaction, and visual analog scale (VAS) for pain. Evidence levels were determined using GRADE profile.
RESULTS
The 16 included studies involved 918 cases, 418 in the surgical group and 500 in the nonsurgical group. The results of the meta-analysis showed higher mean Kujala score (SMD = 0.79, 95% confidence interval [CI] [0.3, 1.28], P = .002) and lower rate of redislocation (OR = 0.44, 95% CI [0.3, 0.63], P < .00001) in the surgical group than the nonsurgical group, but showed insignificant differences in the incidence of patellar subluxation (OR = 0.61, 95% CI [0.36, 1.03], P = .06), satisfaction of patients (OR = 1.44, 95% CI [0.64, 3.25], P = .38), and VAS (SMD = 0.84, 95% CI [-0.36, 9.03], P = .84).
CONCLUSION
For patients with primary acute patellar dislocation, surgical treatment produces a higher mean Kujala score and a lower rate of redislocation than nonsurgical treatment.
Topics: Conservative Treatment; Humans; Orthopedic Procedures; Patellar Dislocation; Treatment Outcome
PubMed: 31335681
DOI: 10.1097/MD.0000000000016338 -
Indian Journal of Orthopaedics Feb 2023The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing...
PURPOSE
The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing for patients with first-time patellar dislocation.
METHODS
Databases of PubMed, EMBASE, Cochrane Library and Web of Science were searched up to May 8, 2022. Only articles treating first-time patellar dislocation with MPFL reconstruction, MPFL repair and medial reefing were included in the analysis. Eligible identification, data extraction, quality assessment and statistical analysis were performed by two independent reviewers. The primary outcome measures were the incidences of postoperatively redislocation and reoperation. The second outcomes were the Kujala functional score and complications (including infection, osteoarthritis, and loss of range of motion).
RESULTS
Twenty-two studies involving 668 patients met the inclusion criteria. Of which, four studies involving 126 patients were in MPFL reconstruction group, ten studies involving 220 patients in MPFL repair group and 9 studies involving 322 patients in medial reefing group. Our results showed that the MPFL reconstruction (1.8%, 95% CI - 0.5 to 4.0%) had a significantly lower rate of postoperative redislocation and reoperation rate than the MPFL repair (15.4%, 95% CI 5.2-25.7%) and medial reefing (18.0%, 95% CI 9.3-26.7%). Besides, no significant differences were found in the Kujala score and complication rate among the three treatments.
CONCLUSION
The available evidence demonstrated that MPFL reconstruction could achieve significantly lower redislocation rate and reoperation rate than MPFL repair and medial reefing after first-time patella dislocation. Furthermore, there was not enough evidence to reveal that MPFL reconstruction provided better functional outcome compared with MPFL repair and medial reefing. MPFL reconstruction is a preferred surgical treatment for patients with first-time patellar dislocation.
LEVEL OF EVIDENCE
Level IV, systematic review of Level I-IV.
PubMed: 36777132
DOI: 10.1007/s43465-022-00770-w -
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 -
Journal of Orthopaedic Surgery and... Jan 2022Patellar dislocations in patients presenting with recurrent patellofemoral instability can damage the surrounding structures, limiting patient's participation to...
BACKGROUND
Patellar dislocations in patients presenting with recurrent patellofemoral instability can damage the surrounding structures, limiting patient's participation to recreational activities and quality of life. This study evaluated frequency, location, and extent of associated injuries in patients with recurrent patellar dislocation.
METHODS
This systematic review was conducted according to the PRISMA checklist. PubMed, Google scholar, Embase, and Web of Science databases were accessed in July 2021. All the published clinical studies reporting frequency, location, and extent of soft tissue lesions in patients with recurrent patellar dislocations were accessed.
RESULTS
Data from 9 articles (232 patients) were retrieved. The mean age of the included patients was 21.2 ± 5.6 years. 84.8% of patients suffering from recurrent patellar dislocations demonstrated patellar chondral defects: medial facet (34.9%), while patellar crest (34.8%) and lateral facet (17%). 27.8% of patients demonstrated trochlear chondral injuries.
CONCLUSION
Chondral defects of the medial facet and the crest of the patella are the most common in patients with recurrent patellofemoral instability.
Topics: Adolescent; Adult; Female; Humans; Joint Dislocations; Joint Instability; Male; Patella; Patellar Dislocation; Patellar Ligament; Patellofemoral Joint; Quality of Life; Plastic Surgery Procedures; Recurrence; Treatment Outcome; Young Adult
PubMed: 35101078
DOI: 10.1186/s13018-022-02911-1 -
Orthopaedic Surgery Nov 2023The optimal surgical intervention for lateral patellar instability remains a topic of controversy despite satisfactory clinical outcomes and low re-dislocation rates... (Meta-Analysis)
Meta-Analysis Review
The optimal surgical intervention for lateral patellar instability remains a topic of controversy despite satisfactory clinical outcomes and low re-dislocation rates reported in numerous studies following medial patellofemoral ligament reconstruction (MPFLR) with and without tibial tubercle transfer (TTT). The purpose of this systematic review and meta-analysis is to investigate the hypothesis that combining MPFLR with TTT provides reduced complication rates and improved clinical outcomes to isolated MPFLR in patients with lateral patellar instability. We conducted a comprehensive systematic review and meta-analysis of comparative trials involving MPFLR with and without TTT, sourcing data from PubMed, the Cochrane Library, Embase, and Web of Science. The primary clinical outcomes analyzed included the Kujala score, the Lysholm score, complication rates, and the Caton-Deschamps index (CDI). Random or fixed effects were used for the meta-analysis. Postoperatively, there were no significant differences observed in the Kujala and Lysholm scores between MPFLR and MPFLR + TTT (p = 0.053). At the final follow-up, the CDI had decreased 0.015 (95% CI -0.044, 0.013; p = 0.289) points in the MPFLR group, with no statistical significance. In contrast, the MPFLR + TTT group demonstrated a significant decrease of 0.207 (95% CI -0.240, -0.174; p = 0.000) points in CDI. Notably, the complication rate was higher in the MPFLR + TTT group compared to the MPFLR-only group (RR = 2.472; 95% CI 1.638, 3.731; p = 0.000). Both MPFLR and MPFLR + TTT procedures yield significant improvements in the Kujala and Lysholm scores. However, the MPFLR + TTT approach results in an apparent improvement in CDI and corrects patellar maltracking, particularly in cases involving high tibial tuberosity-trochlear groove (TT-TG) (>20 mm) or patella alta (CDI > 1.2), while MPFLR alone cannot. It is essential to consider the higher complication rate of MPFLR + TTT, which suggests that MPFLR alone may be sufficient for patients without high TT-TG or patella alta.
Topics: Humans; Joint Instability; Patellar Dislocation; Patellofemoral Joint; Knee Joint; Ligaments, Articular; Tibia; Patella; Retrospective Studies
PubMed: 37688429
DOI: 10.1111/os.13870 -
The Knee Apr 2024Children and adolescents have the highest incidence of patellar instability among the population. We aimed to identify patho-morphological and epidemiological factors... (Review)
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.
PubMed: 38657526
DOI: 10.1016/j.knee.2024.03.009 -
Knee Surgery, Sports Traumatology,... Oct 2014While there are numerous anatomic contributors to patellar instability, the role of patella alta has been traditionally under-appreciated. The goal of this systematic... (Review)
Review
PURPOSE
While there are numerous anatomic contributors to patellar instability, the role of patella alta has been traditionally under-appreciated. The goal of this systematic review is to identify the described techniques for treating patella alta in skeletally mature patients with episodic patellar dislocation (EPD) and review their published results.
METHODS
A comprehensive literature review was performed to identify published surgical techniques and their results. Tibial tubercle distalization is the primary described treatment for patellar alta in patients with EPD, and five studies reporting results of this procedure were reviewed.
RESULTS
Tibial tubercle distalization was generally successful in normalizing patellar height and preventing recurrent patellar dislocation. Physical examination tests for instability such as patellar apprehension remained positive in 15 to 33% of patients. Patient-reported outcomes were rarely reported and difficult to interpret given the lack of pre-operative values or comparison groups.
CONCLUSION
Tibial tubercle distalization is an effective technique for correction of patellar height and preventing recurrent patellar dislocations. More comparative studies are required to evaluate patient-reported outcomes of this technique, the effect of an associated tubercle medialization, and the results of supplementing distalization with procedures such as MPFL reconstruction.
LEVEL OF EVIDENCE
Systematic review of case series, Level IV.
Topics: Humans; Joint Instability; Knee Joint; Patella; Patellar Dislocation; Tibia; Treatment Outcome
PubMed: 23392290
DOI: 10.1007/s00167-013-2445-8 -
The American Journal of Sports Medicine Aug 2012Patellofemoral instability affects activities of daily living and hinders athletic participation. Over the past 2 decades, more attention has been paid to medial... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Patellofemoral instability affects activities of daily living and hinders athletic participation. Over the past 2 decades, more attention has been paid to medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocations/subluxations. Numerous techniques have been reported; however, there is no consensus regarding optimal reconstruction.
PURPOSE
This study sought to report on the various techniques for MPFL reconstruction described in the literature and to assess the rate of complications associated with the procedure.
STUDY DESIGN
Meta-analysis.
METHODS
A systematic review of the literature was performed in early October 2010 using keywords "medial patellofemoral ligament," "MPFL," "reconstruction," "complication(s)," and "failure(s)." Articles meeting the inclusion criteria were reviewed. Graft choice, surgical technique, outcome measures, and complications were recorded and organized in a database. Descriptive statistical analysis was performed on the data collected.
RESULTS
Twenty-five articles were identified and reviewed. A total of 164 complications occurred in 629 knees (26.1%). These adverse events ranged from minor to major including patellar fracture, failures, clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain. Twenty-six patients returned to the operating room for additional procedures.
CONCLUSION
Medial patellofemoral ligament reconstruction has a high rate of success for patients with patellofemoral instability; however, the complication rate of 26.1% associated with this procedure is not trivial. This study quantified complications and documented the variety of complications reported in outcomes-based literature.
Topics: Humans; Orthopedic Procedures; Patellar Dislocation; Patellar Ligament; Patellofemoral Joint; Plastic Surgery Procedures; Recurrence
PubMed: 22679297
DOI: 10.1177/0363546512442330 -
Orthopaedic Journal of Sports Medicine Nov 2021Studies on the clinical outcomes of derotational femoral osteotomy to treat recurrent patellar dislocation in the presence of increased femoral anteversion are limited. (Review)
Review
BACKGROUND
Studies on the clinical outcomes of derotational femoral osteotomy to treat recurrent patellar dislocation in the presence of increased femoral anteversion are limited.
PURPOSE
To investigate the role of derotational femoral osteotomy in the treatment of recurrent patellar dislocation in the presence of increased femoral anteversion.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching the Medline, Embase, Web of Science, and Cochrane Library databases through February 10, 2021. Included were studies of skeletally mature patients presenting with recurrent patellar dislocation and exhibiting increased femoral anteversion who subsequently underwent derotational femoral osteotomy. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. The basic characteristics of each study were recorded and analyzed: characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications.
RESULTS
A total of 6 studies with 163 patients (170 knees) were included. Sample sizes ranged from 7 to 66 patients, and the patients were predominantly women (range, 79%-100%). The mean age and follow-up ranges were 18 to 28 years and 16 to 44 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting pre- and postoperative outcomes, significant improvements were found in the Lysholm score (from 24.8 to 44.1), Kujala score (from 15.8 to 41.9), International Knee Documentation Committee score (from 11.0 to 28.0), and visual analog scale for pain (from 2.0 to 3.7). All studies reported postoperative complications, giving an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period.
CONCLUSION
For recurrent patellar dislocation in the presence of increased femoral anteversion, combination treatment with derotational femoral osteotomy led to favorable clinical outcomes with a low redislocation rate. However, there was no consensus among researchers on the indications for derotational femoral osteotomy in the treatment of recurrent patellar dislocation.
PubMed: 34881342
DOI: 10.1177/23259671211057126 -
Journal of Orthopaedics 2020Patellar dislocations are a significant injury with the potential for long term problems. Little work has been done on establishing the mechanism by which this injury... (Review)
Review
BACKGROUND
Patellar dislocations are a significant injury with the potential for long term problems. Little work has been done on establishing the mechanism by which this injury occurs.
OBJECTIVES
To determine the mechanism of injury of a patella dislocation based on the available published literature and compare them to already proposed theories.
METHODS
A systematic review of the literature was conducted following searches performed on MEDLINE, EMBASE and ProQuest from the earliest year of indexing using the following search terms in any combination: "patella", "dislocation", "mechanism of injury", "anatomy", "biomechanical" and "risk factor". A broad inclusion criteria was used that included studies that looked at patellar dislocations and instability with respect to the patellofemoral joint (PFJ) kinematics or altered kinematics of the PFJ. Studies that did not address the kinematics or biomechanics of the PFJ were excluded. Studies were appraised based on their methodology using a combination of the Critical Appraisal Skills Programme tool and the Quality Appraisal for Cadaveric Studies.
RESULTS
113 studies were identified from a search of MEDLINE, EMBASE and ProQuest databases. Following application of our inclusion criteria, a total of 23 studies were included in our review. 18 of these studies were cadaveric biomechanical studies. The remaining studies were anatomical, imaging based, and a computer simulation based study.
CONCLUSIONS
These biomechanical and kinematic studies provide some evidence that a dislocation is likely to occur during early knee flexion with external rotation of the tibia and contraction of the quadriceps. There is limited evidence to support other elements of proposed mechanisms of dislocation.
PubMed: 32042233
DOI: 10.1016/j.jor.2019.11.018