Mean Kujala Score Research Articles

Long-term clinical results of the crosse de hockey procedure for recurrent patellar dislocation.

A gold standard procedure has not been established for recurrent patellar dislocation because of multifactorial etiologies. We have been performing crosse de hockey procedure, which is a combination of medial and anterior transfer of the tibial tuberosity, in our institution since 1993. This study aimed to investigate the long-term clinical results of this procedure. A total of 19 patients (21 knees) underwent the crosse de hockey procedure for recurrent patellar dislocation. Of these patients, four were lost to follow-up. The remaining 17 knees in 15 patients (5 male and 10 female) were included in this study. The mean follow-up period was 13.2 years (range: 5-22.6 years). Clinical evaluation was performed using the Kujala score. Radiographic indicators, such as modified Insall-Salvati ratio, sulcus angle, congruence angle, tilting angle, lateral shift ratio, and the progression of patellofemoral osteoarthritis (OA), were measured. Positive apprehension sign and redislocation were not observed in any of the patients. The mean Kujala score was significantly improved from 36.5 ± 18.0 preoperatively to 92.6 ± 9.9 at the final follow-up. Definite OA (a grade 2 or more using the Iwano grading system) was not observed in the patellofemoral joint at the final follow-up. The crosse de hockey procedure showed satisfactory long-term clinical results for recurrent patellar dislocation. This procedure could prevent the progression of patellofemoral OA because of the unloading effect of the patellofemoral joint by anteromedial transfer of the tibial tuberosity.

Combined Reconstruction of the Medial Patellofemoral Ligament (MPFL) and Medial Quadriceps Tendon-Femoral Ligament (MQTFL) for Patellar Instability in Children and Adolescents: Surgical Technique and Outcomes.

A variety of surgical options exist to treat the challenging problem of recurrent patellar instability in children and adolescents. The goal of the current study is to describe a novel combined reconstruction technique of both the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon-femoral ligament (MQTFL) and report patient outcomes of a single-surgeon series. All patients studied underwent simultaneous MPFL and MQTFL reconstruction for patellar instability using gracilis allograft. Demographic, clinical, and radiographic data were collected. Subjective outcomes were assessed for a minimum of 1 year postoperatively. Twenty-five patients (27 knees), including 15 female and 10 male individuals with an average age of 15.0±2.2 years (range, 10.3 to 18.9), were included. Prior ipsilateral patellofemoral surgery had been performed in 6 of 25 (24%) patients. Simultaneous hemiepiphysiodesis for valgus deformity at the time of combined reconstruction was performed in 5 of 25 (20%) patients. Preoperative imaging showed a mean tibial tubercle-trochlear groove of 17.2±3.8, Caton-Deschamps Index (CDI) of 1.13±0.16, and trochlear dysplasia Dejour A/B [22/26 (85%)] or Dejour C/D [4/26 (15%)]. A total of 18 patients (19 knees, 72%) returned outcomes questionnaires at a mean 2.0±0.5 years after surgery. Mean Kujala, Pedi-IKDC, and Lysholm scores were 85.9±13.9, 81.5±15.2, and 84.3±13.5, respectively. Later revision procedure (tibial tubercle osteotomy) for recurrent patellar instability was required in 2 of 25 patients (8%) patients, and another patient reported persistent instability not requiring revision. Return to sports was possible in 10 of 13 self-reported athletes (77%) at a mean of 5.8±3.9 months (range, 2 to 15). The present study describes a combined MPFL-MQTFL reconstruction technique with favorable short-term results. Although particularly useful in the skeletally immature patient where tibial tubercle osteotomy should be avoided and patellar fixation minimized, combined reconstruction may potentially be appropriate for older patients with patellofemoral instability as well. This technique more closely recreates the native anatomy of both the MPFL and MQTFL, may decrease the risk of patellar fracture, and can be useful in the revision setting. Level IV.

Evaluation of the results of double-bundle transpatellar medial patellofemoral ligament reconstruction using semitendinosus autograft

Background The medial patellofemoral ligament (MPFL) is the main static patellar stabilizer beyond 30° of knee flexion. Nowadays, MPFL reconstruction is the gold standard operation for recurrent patellar dislocation. Aim To assess the results of double-bundle transpatellar MPFL reconstruction using semitendinosus graft. A case series study held at Alexandria University Hospitals. Patients and methods Between May 2011 through October 2013, 58 patients with recurrent patellar dislocation were treated by MPFL reconstruction using semitendinosus tendon autograft. Their mean age was 20.05 years. There were 13 men and 45 women. All patients were followed up for at least 24 months. Patients were assessed using the Kujala score. Results The overall results were considered good to excellent. No case reported postoperative redislocation. All patients had negative apprehension test postoperatively. The mean Kujala score improved from preoperative 49 (range: 35–64) points to postoperative 93.9 (P Conclusion The use of transpatellar technique for MPFL reconstruction has very low complication rate of more than 24 months follow-up. There were no reported cases of patellar fractures or loss of knee flexion.

Recurrence of Patellar Instability in Adolescents Undergoing Surgery for Osteochondral Defects Without Concomitant Ligament Reconstruction

Background: First-time patellar dislocation with an associated chondral or osteochondral loose body is typically treated operatively to address the loose fragment. The incidence of recurrent instability in this patient population if the medial patellofemoral ligament (MPFL) is not reconstructed is unknown. Purpose: To determine the recurrent instability rate in patients undergoing surgery for patellar instability with chondral or osteochondral loose bodies, as well as to identify and stratify risk factors for recurrent instability. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective analysis of adolescent patients treated operatively for acute patellar dislocation with associated chondral or osteochondral loose bodies between 2010 and 2016 at a single pediatric level I trauma center with minimum 2-year follow-up. Potential demographic, injury-related, radiographic, and surgical risk factors were recorded. The primary outcome variable was recurrent subluxation and/or dislocation. Secondary outcome variables included need for additional procedures, Kujala score, Single Assessment Numerical Evaluation (SANE) score, and patient satisfaction. Results: Forty-one patients were included. In total, 61% experienced recurrent instability at a mean follow-up of 4.1 years and 39% required subsequent MPFL reconstruction. Tibial tubercle-trochlear groove (TT-TG) distance greater than 15 mm was a risk factor for recurrent instability (P = .03). Patients with TT-TG distance greater than 15 mm and greater than 20 mm had recurrent instability rates of 75% and 86%, respectively. MPFL repair did not reduce the rate of recurrent instability (P = .87). Recurrent instability was associated with significantly worse mean Kujala (93.9 vs 83.0; P = .01), SANE (88.9 vs 73.1; P = .01), and patient satisfaction scores (9.4 vs 7.3; P = .002). Conclusion: If the MPFL is not reconstructed during index loose body treatment, children have a 61% recurrent instability rate. Patients with TT-TG distance greater than 15 mm, and particularly greater than 20 mm, are at highest risk for recurrent instability.

Accuracy of Schottle's point location by palpation and its role in clinical outcome after medial patellofemoral ligament reconstruction

IntroductionMedial patellofemoral ligament (MPFL) reconstruction is performed for the recurrent patellar dislocation (RPD). The crux of sound clinical results depends upon accurate placement of the graft at or within the 7-mm circle of Schottle point (acceptable position) over the femur. Most studies recommend the location of Schottle's point using intraoperative fluoroscopy or seldom by clinical palpation. We conducted a clinical study to understand the accuracy of locating Schottle's point by clinical palpation and its effect on outcome after MPFL reconstruction. Method30 patients with RPD were included in this retrospective study after MPFL reconstruction. Post-operative CTscan was performed to locate the position of the femoral tunnel using Servien grid criteria and Schottle's point location. The clinical outcome was assessed using Lysholm and Kujala Scores at the end of a minimum of two years. Results30 patients (11 male, 19 female) with a mean age of 24.8 years (range, 16–45 years) were followed for a mean of 42 months (range, 24–96 months). Mean Kujala score improved from 53.8 to 91.5 (p = 0.0001), and Lysholm score improved from 59.0 to 93.3 (p = 0.0001) in all 30 patients. Post-operative CT assessment revealed 19 patients (63.3%) had a tunnel in an acceptable position and 11 patients (36.7%) in an unacceptable position. Eight of the eleven unacceptable tunnels were placed in the anteroposterior direction, and three in superior-inferior direction. However, there was no significant difference between the Lysholm and Kujala scores of patients with acceptable versus unacceptable tunnels. ConclusionPlacement of the femoral tunnel over the medial femoral condyle by the palpatory method is accurate in close to 2/3rd of the cases only whereas rest 1/3rd may fall outside the acceptable position. Hence, it is recommended to confirm the placement of femoral tunnel with intraoperative fluoroscopy at the acceptable position to avoid error. Level of studyRetrospective case series, level IV.

Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study.

The medial patellofemoral ligament (MPFL) is the most important ligamentous stabilizer preventing lateral patella dislocation. Numerous surgical procedures for MPFL reconstruction have been described in the literature. The aim of this study was to investigate the clinical, functional and patient-reported (PROM) outcomes 2 years after minimally invasive MPFL reconstruction performed using an autologous strip of the quadriceps tendon. Thirty-six patients (38 knees) were included in the study. For MPFL reconstruction, a partial thickness autologous quadriceps tendon graft was used. All patients were evaluated clinically and with patient-reported outcome questionnaires including the Tegner, Lysholm and Kujala scores as well as a visual analogue scale (VAS) for pain preoperatively and at 6, 12 and 24 months postoperatively. A functional Back-in-Action (BIA) test battery, including a total of seven stability, agility and jumping tests, was performed on 19 (50%) patients at the final follow-up. One patient was lost to follow-up at 24 months. The mean age at the time of operation was 25.2 ± 6.1years. No redislocations occurred during the period of investigation. The mean Lysholm score improved significantly from 79.3 ± 16.1 preoperatively to 83.2 ± 14.4at 6months, 88.1 ± 11.3at 12months and to 90.0 ± 9.6at 24months follow-up. No change throughout the study period was observed for the median Tegner Activity Score (median 6). The mean Kujala score increased from a preoperative value of 82.0 ± 12.4, to 84.5 ± 8.4at 6months, and 88.2 ± 5.8at 12months up to 88.7 ± 4.5at 24months follow-up. A total of 77.8% of the performed functional BIA tests were equal to or above the norm for patients of the corresponding ages and activity levels. Minimally invasive MPFL reconstruction with a partial thickness strip of quadriceps tendon is a safe and effective treatment for patellofemoral instability. Good clinical, functional and subjective results were observed at the 2-year follow-up. Prospective cohort study, non-randomized, Level IV.

Functional outcome of Medial patellofemoral ligament injury (MPFL) reconstruction in recurrent patellar dislocation

Introduction: Patella dislocation is defined as interposition of patella out of the trochlear groove. Patella dislocation is typically lateral and most often traumatic. Surgical treatment for patellar dislocation has evolved from the initial medial reefing to the present day anatomical reconstruction of MPFL which is thought to be the most appropriate treatment. MPFL reconstruction has been recommended in adults over the past decade after recurrent patellar instability. Many studies have shown good clinical outcome with this procedure compared to others. This study is undertaken in order to evaluate, clinical results of MPFL reconstruction. Materials and methods: This prospective study included 20 cases of recurrent dislocation of patella patients of either sex fitting the inclusion criteria at the Orthopedic Department of Sanjay Gandhi Institute of Trauma and Orthopedics, Bangalore from September 2016 To December 2017. Patients admitted with MRI proven mpfl tear after meeting the inclusion and exclusion criteria are selected. They will undergo detailed history, clinical and radiological evaluation. Mpfl repair was done by a single trained surgeon. Post-operative rehabilitation as per standard protocol. Postoperative evaluation done at 1 year. Lysholm and kujala scoring done at preoperative and postoperative follow-ups. Results: The mean age in our study is 24.4years. Majority are in the age group 15 to 45yrs. Mean kujala score increased from 50.8 to 93.7 which is statistically significant (p

Outcomes of medial patellofemoral ligament reconstruction in patients with patella alta

ObjectiveTo compare the clinical outcomes and the results of knee functional scores in patients with normal patellar height and patella alta who underwent isolated medial patellofemoral ligament reconstruction. MethodsA total of 37 knees from 33 patients with recurrent patellar dislocation who underwent isolated medial patellofemoral ligament reconstruction were included. Retrospectively, the postoperative clinical results were compared using the Kujala and Lysholm scores in the group of patients with normal patellar height and in those with patella alta. ResultsThe sample consisted of 37 patients; 16 knees of 14 patients in the group with normal patellar height, 21 knees of 19 patients in the group with patella alta. In the first group, the mean Kujala score was 85.8 and the mean Lysholm score was 85.6. In the second, the mean Kujala score was 78.1 and the mean Lysholm score was 79.7. No significant differences were observed between the groups in relation to the Lysholm (p=0.296) and Kujala scores (p=0.181). ConclusionIsolated medial patellofemoral ligament reconstruction presented similar results in patients with normal patellar height and patella alta.

Resultados da reconstrução isolada do ligamento patelofemoral medial em pacientes com patela alta

ObjectiveTo compare the clinical outcomes and the results of knee functional scores in patients with normal patellar height and patella alta who underwent isolated medial patellofemoral ligament reconstruction. MethodsA total of 37 knees from 33 patients with recurrent patellar dislocation who underwent isolated medial patellofemoral ligament reconstruction were included. Retrospectively, the postoperative clinical results were compared using the Kujala and Lysholm scores in the group of patients with normal patellar height and in those with patella alta. ResultsThe sample consisted of 37 patients; 16 knees of 14 patients in the group with normal patellar height, 21 knees of 19 patients in the group with patella alta. In the first group, the mean Kujala score was 85.8 and the mean Lysholm score was 85.6. In the second, the mean Kujala score was 78.1 and the mean Lysholm score was 79.7. No significant differences were observed between the groups in relation to the Lysholm (p = 0.296) and Kujala scores (p = 0.181). ConclusionIsolated medial patellofemoral ligament reconstruction presented similar results in patients with normal patellar height and patella alta.

Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial

Background: A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. Purpose: (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. Results: The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively (P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. Conclusion: Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).

Adolescent Medial Patellofemoral Ligament Reconstruction: A Comparison of the Use of Autograft Versus Allograft Hamstring.

Background:Recurrent patellar instability is commonly treated with medial patellofemoral ligament reconstruction (MPFLR), and the use of allograft in anterior cruciate ligament reconstructions has demonstrated inferior outcomes.Purpose:To compare the outcomes of allografts versus autografts in adolescent MPFLR for patellar instability.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective chart review was completed on patients younger than 18 years who underwent MPFLR for recurrent instability after failed nonoperative management over an 8-year period with a minimum 2-year follow-up. Patients were divided into autograft or allograft hamstring cohorts for comparison. Primary outcome measures were return to normal activity, incidence of redislocation/subluxation, pain, stiffness, other complications, and Kujala scores. Statistical analysis using unpaired t tests was performed, with an alpha value set at P < .05.Results:After criteria were applied, 59 adolescents (36 allograft, 23 autograft; 38 girls, 21 boys) with a mean ± SD age of 15.2 ± 1.7 years and a mean follow-up of 4.1 ± 1.9 years (allograft, 3.3 ± 1.1 years; autograft, 5.7 ± 2.1 years; P ≤ .001) were included. Seven patients had concurrent osteotomies (3 allograft, 4 autograft), 11 patients had concurrent loose body removals (5 allograft, 6 autograft), and 9 patients had concurrent lateral release (7 allograft, 2 autograft). Between groups, no significant difference was found in change between preoperative and most recent follow-up (mean, 1.2 ± 2.1) or rate of return to sports (mean, 73.3%). In total, 9 surgeries failed (3 allograft, 6 autograft). For the surviving grafts, a statistical difference in mean Kujala scores at final follow-up was noted (allograft, 92.7; autograft, 97.4; P = .02).Conclusion:We identified no significant differences in return to activity, pain score changes, and incidences of failure between patients undergoing MPFLR with allograft versus autograft. Although teenagers with surviving autograft MPFLR reported statistically higher Kujala scores, the mean score difference of 5 points was not clinically significant. It appears that using allograft tendon instead of autograft tissue for MPFLR in this teenage population does not adversely affect long-term outcomes.

Long-Term Clinical Results of Double Bundle Reconstruction of the Medial Patellofemoral Ligament for Patellar Instability.

Medial patellofemoral ligament (MPFL) reconstruction is a satisfactory technique for patellar instability, and the anatomical double bundle variant is recommended for better clinical results. However, long-term outcomes are still uncharacterized. This study aimed to assess the effectiveness of double bundle reconstruction of the MPFL for patellar instability by means of established scores. A total of 68 patients with chronic patellar instability who underwent surgery from May 2005 to February 2010 were included prospectively. Anatomical double reconstruction of the MPFL with the semitendinosus tendon was conducted. Tegner Activity Scale (TAS), Kujala score, Lysholm knee score, and objective physical examination were assessed during follow-up. Median follow-up time for the patients was 8 (range, 6-10) years. Eight patients were lost to follow-up after 2 years. Preoperative mean TAS was 2.85 ± 0.78, increased to 4.91 ± 0.84 at 6 months and 7.26 ± 0.78 at 2 years postoperatively, and was 7.82 ± 0.89 at last follow-up. At last follow-up, pain free at rest was achieved in all patients; and 8 patients had knee pain in activities of daily living. Mean Kujala score was 57.53 ± 8.59 preoperatively, and increased to 61.22 ± 6.46, 89.51 ± 3.90, and 88.92 ± 3.84 at 6 months, 2 years postoperatively, and at last follow-up, respectively. Lysholm scores were also increased from preoperative values of 43.53 ± 10.20 to 58.22 ± 6.80, 89.37 ± 4.38, and 89.67 ± 4.13 at 6 months, 2 years postoperatively, and at last follow-up, respectively. Range of motion was 121.44 ± 12.69, 129.71 ± 6.39, 130.93 ± 5.67, and 130.78 ± 5.80 at preoperative point, 6 months, 2 years postoperatively, and at last follow-up, respectively. Long-term clinical results of double bundle reconstruction of the MPFL for patellar instability were encouraging.

Clinical Outcome of Anatomical Transportal Arthroscopic Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft.

Good clinical outcome and return to sport and daily functions after anatomical arthroscopic anterior cruciate ligament (ACL) reconstruction is goal standard in this surgery. but to date, there are different challenging issues between orthopedic surgeons regarding graft selection and surgical techniques. We retrospectively reviewed the patients who underwent anatomical arthroscopic one bundle ACL reconstruction with quadruple hamstring tendon autograft from 2010 to 2016 in our orthopedic sport medicine center. Eighty-two eligible patients (82 knees) who had met our inclusion criteria were examined in terms of knee stability by clinical examinations and KT 2000 arthrometer and - also were evaluated regarding variables related to their health and knee status with a mean 48months follow-up. Seventy-seven patients (93.9%) were male and the other 5 cases (6.1%) were female. The mean age was 33 ± 8.06 years old at the time of surgery and mean BMI amount was 26.81 ± 3.72. 78 patients (95%) returned to pre-injury sport activity level after ACL reconstruction and two patients (2.4%) had re-rupture. 63 patients (76.8%) had negative anterior drawer and 67patients (81.8%) negative lachman tests respectively. 10 patients (13%) were found to have positive pivot shift tests which was correlated with pain and a less KOOS scores with a significant difference (P= 0.03). 72 patients (87%) had negative tests in active and 70 (85.4%) had less than 3 mm side to side difference in manual testing by KT2000. Final KOOS score was 70.87 ± 19.76. Mean Lysholm score was 90 ± 4.77. Mean International Knee Documentation Committee (IKDC) score of this study was 85 ± 14.11.Patients who had concomitant partial meniscectomy had significantly lower IKDC scores (P<0.01).Mean kujala score was 79 ± 3.07. The use of quadrupled hamstring tendon autograft besides the most important part of the treatment which is the surgical technique would yield to excellent results in ACL reconstruction both subjectively and objectively. In addition, patient selection and surgeon's experience should be considered in determining the treatment plan for the patients.Level of evidence: IV.

Clinical Outcome of Arthroscopic Lateral Retinacular Release for Symptomatic Bipartite Patella in Athletes

To report the results of arthroscopic lateral retinacular release without excision of the accessory fragment for treatment of symptomatic bipartite patella with a minimum 2-year follow-up. We retrospectively reviewed all cases of symptomatic type III bipartite patella confirmed by radiographs, computed tomography, and magnetic resonance imaging and treated with arthroscopic lateral release from 2005 to 2015. Patients with history of knee fractures or surgery, concomitant meniscal or anterior cruciate ligament (ACL) procedures, and severe arthritic changes of the patellofemoral joint were excluded. Patients were assessed by Kujala score, visual analog scale (VAS), Tegner Activity Scale (TAS), and time to return to sporting activities. Ten patients (11 knees) were clinically reassessed after 69.6 ± 33.3 (range: 25-132; 95% confidence interval [CI]: 47.29-91.99) months from surgery. There was a significant improvement in Kujala (P < .05) and VAS scores (P < .05), and no differences were found between pre- and postoperative TAS scores (P > .05). No complications occurred during the follow-up period. All patients returned to sport after 42.3 ± 11.3 (range: 30-60; 95% CI: 34.71-49.84) days after surgery. The arthroscopic lateral retinacular release of a symptomatic type III bipartite patella without excision of the accessory fragment allowed early return to sporting activities, with excellent symptom relief. Patients had significantly improved mean Kujala and VAS scores without a decrease in the mean TAS scores. Level IV, case series.

Results of operative 4-in-1 patella realignment in children with recurrent patella instability

PurposeRecurrent patellar instability is a cause of knee dysfunction, limitation and pain for children. If nonoperative treatment fails to stabilise the patella, operative realignment and stabilisation have been advocated. Operative techniques in the paediatric population must preserve physeal growth while ensuring stability. We aimed to determine the outcome of children and adolescents who underwent a 4-in-1 patellar realignment (lateral release, medial reefing, Insall tube realignment and Roux-Goldthwaite patella ligament transfer). MethodsConsecutive skeletally immature patients operated in our institution were included in the study. A total of 16 operated knees in 12 patients were recruited. All patients underwent the same procedure after attempting a minimum period of 6 months of non-operative treatment with unsatisfactory results. The main outcome measured was recurrent dislocations. Functional outcomes were assessed using the Kujala score and the Paediatric form of the International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC). ResultsPatients were followed up for a minimum of 3 years. None of the patients sustained further patella dislocations following the operation. In 3 cases, minor patellar maltracking was noted post-operatively but all 3 remained asymptomatic. Three patients had a small area of numbness lateral to the operative incision, which coincided with hypertrophic scarring. There was one case of superficial wound infection. The mean Kujala score was 83.4 ± 11.47 and the mean Pedi-IKDC was 79.5 ± 12.56 at the latest follow-up (minimum of 36 months). ConclusionsThe 4-in-1 patellar realignment is a good procedure in paediatric and adolescent patients with recurrent patella instability. Satisfactory results were observed with a minimal complication and redislocation rate in our series.

''Basket Weave'' Technique Of Mpfl Reconstruction. A Prospective Study In 62 Knees

“Basket Weave’ technique of MPFL reconstruction devised by the author has given encouraging results. It is anatomical and does not require bone tunnels or implants. It restores normal patellar stability and mobility. Combining it with other procedures for patellar instability does not compromise its results. It has a low failure rate. It is a safe, effective, reliable and reproducible technique. MPFL reconstruction methods using bone tunnels and implant fixations are known to compromise results due to rigid fixations and non anatomical reconstructions. These methods are not advisable in the skeletally immature. Implant fixation and bone tunneling methods cannot reconstruct the medial quadriceps tendon femoral ligament (MQTFL) which has a soft tissue attachment to the quadriceps. The “Basket Weave” technique of MPFL reconstruction was devised by the author to overcome deficiencies of other techniques, to avoid bone tunnels and implants, provide an anatomical reconstruction and a physiometric construct with differential tensioning. A prospective study was performed to assess outcomes and complication rate. 62 knees of lateral patellar dislocation were treated in the past 60 months by “Basket Weave” technique of MPFL reconstruction. Cases selected for this reconstruction were symptomatic for patello-femoral instability, had a ‘dislocatable’ patella under examination or were subluxating patellae not responding symptomatically to appropriate physiotherapy. Cases with habitual patellar dislocation, chronic irreducible patellar dislocation, patello-femoral arthrosis and those responding well to physiotherapy were excluded. 42 were female and 20 male knees. The mean age was 20.3 years (range 9-48 years). Mean followup was 24 months. Five knees had previously failed stabilization procedure of lateral release with medial retinacular plication. 35 cases had Dejours Type A or B and 12 had Type C trochlear dysplasia. 1 had excess femoral ante version of 35 degrees. Arthroscopy was performed to assess associated injuries and presence of loose bodies. 8 knees required loose body removal. 6 knees underwent lateral retinacular release. 5 knees had associated tibial tuberosity medialization. 1 knee had an associated anterior cruciate ligament reconstruction. 1 knee with abnormal increased femoral ante version underwent an associated distal femoral derotation osteotomy. An anatomical MPFL reconstruction with MQTFL reconstruction was performed using hamstring autograft. A “Y” graft construct was created with differential tensioning. The proximal limb fixed in 30° knee flexion and the distal limb in 90°. Intraoperative fluoroscopy was not required. Only soft tissue fixation was performed on the femoral and patellar side with this newly devised reconstruction technique and a novel “Pretzel stitch” suturing technique using absorbable sutures. A rapid postoperative rehabilitation protocol was implemented with monthly follow-ups until normalcy and 6 monthly thereafter. All knees achieved full range of motion with normal medio-lateral patello-femoral stability. There was no recurrence of dislocation or subjective instability. No intraoperative complications or major surgery related postoperative complications. 1 patella fracture at 8 months postoperative, was due to a fall from stairs and developed terminal restriction of flexion following fracture fixation. Those in sports could return to their preoperative level of sporting activities (Tegner 1–9). Cases with osteochondral fractures had occasional pain immediate postoperatively which subsided in 1 year. Mean Kujala score improved from 65.4 to 99.6 with KOOS score near normal in all. This novel method of MPFL reconstruction gives excellent results. It avoids bone tunnelling, implants and related complications. It is a safe, effective, reliable and reproducible technique of MPFL reconstruction.

Double-bundle anatomical medial patellofemoral ligament reconstruction with lateral retinaculum plasty can lead to good outcomes in patients with patellar dislocation.

To evaluate the clinical outcomes of double-bundle anatomical medial patellofemoral ligament (MPFL) reconstruction combined with lateral retinaculum plasty versus isolated MPFL reconstruction for patellar dislocation. From 2011 to 2013, 64 patients underwent either double-bundle anatomical MPFL reconstruction combined with lateral retinaculum plasty (Group A, 32 patients), or isolated MPFL reconstruction (Group B, 32 patients). Clinical evaluations were performed 2years post-operatively and included determination of the number of patients with patellar redislocation, the patellar tilt angle, lateral patellar shift, subjective symptoms, and functional outcomes as evaluated with the Kujala score and Lysholm score. No dislocation or subluxation occurred during the 25-month follow-up. Radiographically, the patellar tilt angle was 6.0°±1.7° in Group A and 6.7°±2.0° in Group B, without a significant difference (n. s). The lateral patellar shift was 8.0±2.6mm in Group A and 8.5±2.4mm in Group B (n. s). The mean Kujala score was 91.8±3.7 in Group A and 91.5±3.6 in Group B post-operatively (n. s), and the mean Lysholm score was 92.5±3.8 and 90.8±4.9, respectively (n. s). Double-bundle anatomical MPFL reconstruction with lateral retinaculum plasty is a promising procedure that provides a new option for patellar dislocation. III.

Effective patellofemoral joint stabilization and low complication rates using a hardware-free MPFL reconstruction technique with an intra-operative adjustment of the graft tension.

Even if medial patellofemoral ligament (MPFL) reconstruction is a proven method, complications such as implant loosening, patella fractures, recurrent luxations, knee pain or knee stiffness are frequently described. Besides a correct tunnel positioning and implant-specific complications, this might be caused by difficulties with an appropriate graft tensioning. The study presented here is a necessary first step in exploring our technique of a double-limbed, hardware-free MPFL reconstruction, which provides another way to test and adjust the graft tension before permanent fastening. Thirty consecutive patients (m/f=18/12) with recurrent dislocations were evaluated after a mean follow-up of 24months. Patients who had additional procedures such as a trochleoplasties, tibial tubercle transfers and derotational osteotomies were not included. Besides a standardized clinical examination, different scorings and possible complications were evaluated. The mean Kujala score improved significantly from 57±15 to 92±10. The Lysholm and IKDC score increased significantly from 59±11 to 95±6 and from 49±9 to 89±9, respectively. No patient reported a re-dislocation, subluxation or showed a positive apprehension. A total of 23 patients were engaged in regular physical activities. All but one, who lost interest, returned to the same sports. Because some did not follow our recommendation to return to sports after a rehab of at least 10-12weeks, the period for a return was relatively short (median of 12weeks, range 3-25weeks). Four patients reported a moderate anterior knee pain only occurring after increased loads such as longer runs or workouts. One of these showed a slight flexion deficit of less than 20°. A severe motion deficit or stiffness was not noticed. Even if a larger, clinical outcome study is needed to ensure the efficacy and safety of our method, it seems to provide a good clinical outcome, a correspondingly high satisfaction and a low incidence of complications. The possibility to adjust graft tension might help in minimizing complications caused by difficulties with an appropriate graft tension. IV.

The clinical and radiological results of individualized surgical treatment depending on pathologic abnormalities in recurrent patellar dislocation: low recurrence rate, but unintended patella baja.

To evaluate the clinical and radiological outcomes and chondral lesion change using individualized surgery for recurrent patellar dislocation. A total of 31 knees with recurrent patellar dislocation underwent surgery depending on individual pathologic abnormalities. Pathologic abnormalities including medial laxity, lateral tightness, increased tibial tuberosity (TT)-to-trochlear groove distance (>20mm), and patella alta (Caton-Deschamps ratio >1.2) were evaluated in each patient. The abnormalities were corrected through medial patellofemoral ligament reconstruction, TT distalization, TT anteromedialization, and lateral retinacula release. The mean follow-up period was 33months. There was one recurrent case (3.2%), requiring additional surgery. The mean Kujala scores were significantly (P=0.002) improved from 75.8 (SD 12.4) to 84.6 (SD 13.1). Tegner scores were significantly improved from 3.7 (range 1-9) to 5.4 (range 2-9) (P<0.001), as were and visual analogue scale pain scores from 4.7 (SD 2.5) to 2.6 (SD 2.2) (P=0.001). Caton-Deschamps ratio was significantly decreased from 1.1 (SD 0.2) to 0.9 (SD 0.1) (P<0.001), regardless of TT distalization. Chondral lesions of the patella and trochlear groove were improved or maintained in 57.1 and 71.4% of patients, respectively. Individualized surgery in recurrent patellar dislocation was effective and safe with a low recurrence rate. However, the possibility of unintended patella baja, which might be related to post-operative anterior knee pain, should be considered. IV.

Functional outcome of minimally invasive reconstruction of medial patello femoral ligament using Quadricep tendon graft in recurrent patellofemoral instability

Recurrent patellofemoral instability is a chronic often painful condition most commonly affecting females of 10-17 years. Aim of the study was to evaluate the functional outcome of minimally invasive reconstruction of medial patello femoral ligament using Quadricep tendon graft in recurrent patellofemoral instability.16 cases of recurrent patellar instability treated in a tertiary care hospital from February 2015 to march 2016 were included. All cases undergone surgery by same team after history, physical examination and radiological imaging. After post operative rehabilitation schedule, all were followed up to 8 months and functional outcome was evaluated using Kujala Anterior Knee Pain Scale (AKPS). The mean Q angle was 22.25. Among 16 cases 12 showed congruence angle greater than -6. 13 out of 16 showed a positive basett’s sign. Apprehension and patellar glide test was positive in all cases. The mean Kujala knee score before surgery was 62.50 (range 56-66) out of which 25% of cases showed poor and 75% with fair scores. The mean Kujala score 8 months after surgery was 86. (range 78-97). 12.5% of cases showed excellent outcome 37.5% were having good and cases with fair outcome being 50%. Minimally invasive quadriceps tendon graft for medial patellofemoral ligament reconstruction for chronic patellofemoral instability showed significant improvement in Kujala knee score (P value