Medial Patellofemoral Ligament Repair Research Articles

Comparing Nonoperative Treatment, MPFL Repair, and MPFL Reconstruction for Patients With Patellar Dislocation: A Systematic Review and Network Meta-analysis.

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.

Management of Patellar Instability: A Network Meta-analysis of Randomized Control Trials

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 P 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 P 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 P 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 P 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.

Home-Based Intravenous Analgesia With an Elastomeric Pump After Medial Patellofemoral Ligament Repair: A Case Series

PurposeThe purpose of this study is to show our experience using elastomeric pumps for postoperative pain relief after outpatient medial patellofemoral ligament (MPFL) reconstruction. DesignProspective case series. MethodsPatients (N = 78) with recurrent patella dislocation who underwent MPFL repair using an autogenous semitendinosus tendon graft were included. After discharge, pain was controlled using intravenous analgesia infused by an elastomeric pump for 48 hours. Outcomes regarding pain, complications, overall satisfaction, and knee functionality were assessed. FindingsEarly postoperative pain was mild in 53.8% of patients, and 30.8% patients had no pain at all. Twenty-four hours after surgery, 38.5% patients presented no pain, which increased to 53.8% at 72 hours. Nausea was experienced by 2.6% patients as was vomiting (7.7%) and drowsiness (2.6%). The mean score for patient satisfaction regarding the treatment was 90.2 (60.0-100.0). Moreover, postoperative knee functionality 12 months after the procedure proved to be statistically significantly superior (P <0.05). ConclusionsPostoperative analgesia using an intravenous elastomeric pump allows performance of MPFL reconstruction as an outpatient procedure with satisfactory pain control, complication rates and patient satisfaction.

Medial Patellofemoral Ligament Reconstruction for Adolescents With Acute First-Time Patellar Dislocation With an Associated Loose Body

Background: The management of adolescents with acute first-time patellar dislocation with an associated loose body remains a debated topic. The rate of recurrent dislocation in these patients may be up to 61% if the medial patellofemoral ligament (MPFL) is repaired or not addressed surgically. To our knowledge, a prospective evaluation of MPFL reconstruction for adolescents with acute first-time patellar dislocation with an associated chondral or osteochondral loose body has not been previously performed. Purpose/Hypothesis: The purpose of this study was to analyze patients with a first-time patellar dislocation who required surgery for a loose body, comparing those who underwent MPFL repair or no treatment with those who underwent MPFL reconstruction during the index procedure. The hypothesis was that performing MPFL reconstruction would reduce the rate of recurrent instability and improve patient-reported outcomes compared with MPFL repair or no treatment. A secondary objective was to report outcomes of those patients who underwent reconstruction versus those who did not. Study Design: Case series; Level of evidence, 4. Methods: This was a prospective analysis of adolescents treated with MPFL reconstruction for acute first-time patellar dislocation with associated loose bodies between 2015 and 2017 at a single pediatric level 1 trauma center with minimum 2-year follow-up. Retrospective analysis was previously performed for a similar cohort of adolescents treated with MPFL repair or no treatment. Patient characteristic data, radiographic measurements, and surgical variables were compared. Primary outcome measures included recurrent subluxation or dislocation and the need for further stabilization procedures. Secondary outcomes included Kujala score, Single Assessment Numeric Evaluation score, patient satisfaction, and ability to return to sport. Results: A total of 76 patients were included, 30 in the MPFL reconstruction cohort and 46 in the MPFL repair or no-treatment cohort. The only difference noted in patient characteristic, radiographic, or surgical variables was a smaller Insall-Salvati ratio in the reconstruction group (1.29 vs 1.42; P = .011). Compared with MPFL repair or no treatment, MPFL reconstruction was associated with less recurrent instability (10.0% vs 58.7%; P < .001), fewer secondary procedures (6.7% vs 47.8%; P < .001), and more frequent return to sports (66.7% vs 39.1%; P = .003). No differences in patient-reported outcomes were noted. Conclusion: Performing concomitant MPFL reconstruction in adolescents with first-time patellar dislocation and an intra-articular loose body results in a 5-fold reduction in recurrent instability, reduces the need for subsequent surgery, and improves patients’ ability to return to sports compared with repairing or not treating the MPFL.

Medial Patellofemoral Ligament Reconstruction Using Suture Tape for Patellofemoral Joint Instability.

ObjectiveTo describe a surgical technique using suture tape for reconstruction of the medial patellofemoral ligament (MPFL). This technique restores the stability of the reconstructed ligament and has excellent postoperative outcomes.MethodThis is a retrospective analysis. From January 2016 to June 2018, 17 patients underwent MPFL reconstruction using high‐strength suture (FiberTape; Arthrex) augmentation, with at least 12 months of follow up. There were 11 female and 6 male patients. The mean age at the time of MPFL reconstruction was 22.1 years (range 13–34 years). Clinical outcomes included pain level, knee range of motion, passive patellar hypermobility, and maltracking at follow‐up. The lateral patellofemoral angles, congruence angles, and patellar tilt angles were measured in a skyline view by CT at 30° of knee flexion at 12 months. Functional outcomes were assessed using the Lysholm knee scoring scale, the SF‐12 score, the Tegner score, and the Crosby and Insall grading system at yearly follow‐up.ResultNo patients were lost at the last follow up. One patient had recurrence of patellar dislocation and none of the others had serious complications. The success rate of MPFL repair for preventing recurrent dislocations was 94.1% (16 of 17 knees). Fifteen knees had full range of motion of more than 130°. At follow‐up, 2 knees were judged to have mild hypermobility and none had severe hypermobility or maltracking. Using the Crosby and Insall grading system, 12 knees (70.6%) were graded as excellent, 4 knees (23.5%) as good, 1 knee (5.9%) as fair to poor, and none as worse at the last follow‐up assessment. In all patients, the Lysholm knee score (55.12 ± 13.52 vs 79.88 ± 7.50, P < 0.01), the SF‐12 score (47 ± 9.53 vs 65.24 ± 12.82, P < 0.01), and the Tegner score (2.76 ± 1.39 vs 6.53 ± 1.70, P < 0.01) had improved at their 12‐month follow up. Compared with preoperative radiological findings, there was a significant improvement in lateral patellofemoral angle (−10.24 ± 7.10 vs 6 ± 5.43, P < 0.01), patellar tilt angle (26.53 ± 7.23 vs 9.88 ± 4.24, P < 0.01), and congruence angle (29.59 ± 11.95 vs −8.65 ± 4.86, P < 0.01).ConclusionThe use of FiberTape in MPFL reconstruction can improve the stability of the knee following surgery and has good midterm clinical results and low complication rates.

Intraoperative axial patellar imaging: a new technique

Background: The medial patellofemoral ligament (MPFL) functions by providing patellar stability and preventing lateral displacement of the patella. Surgical fixation is commonly recommended for MPFL tears in the form of MPFL reconstruction via anatomic techniques. Intraoperative fluoroscopy is critical for identifying anatomical landmarks during surgery. Using the C-arm, both anteroposterior and lateral views are routinely obtained, leaving the surgeon blinded to the angle of approaching the patella. Thus, our team saw a need to develop a method to capture an axial-type view of the patella using available intraoperative imaging technology. Technique: After guide-pin insertion, fluoroscopy is positioned for an anteroposterior view. The knee is hyperflexed while externally rotating the tibia and ankle. The patient’s ankle is slightly below the edge of the operating table, causing the tibia to rotate out of view of the radiograph. The C-arm is angled cephalad, approximately 20 to 30 degrees with the C-arm lowered, the operating table is raised until the knee almost touches the C-arm. The angle of tibial rotation and knee flexion is adjusted to obtain a view that closely resembles is the Merchant view. Our axial patellofemoral fluoroscopic technique augments traditional anteroposterior and lateral views by providing increased accuracy of patellar fixation in relation to the patellofemoral joint. Discussion: As MPFL reconstruction and repair procedures become more common, there will be a desire to improve upon the technique and approach to the procedure. Anatomic positioning of the graft is the most important prognostic factor in determining success of the operation. To decrease complications, such as patellar fracture, accuracy of patellar fixation placement is paramount, and any measure to ensure proper graft placement should be utilized. Conclusions: Our technique established more precise guide-pin placement for the patellar tunnel. It also reduced time spent evaluating patellar fixation via additional orthogonal imaging. This could be associated with better outcomes and avoidance of common complications such as patellar fracture attributed to violation of the anterior cortex. Level of Evidence: Level V.

Comparison of MPFL Repair Versus MPFL Reconstruction for Refractory Patella Instability in Patients Under 18 Years Old

Background:The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint against lateral patellar displacement. Surgery to address MPFL incompetence is the current gold standard for recurrent patellofemoral instability. In the young patient, controversy remains regarding the role of MPFL repair in the setting of recurrent patella instability.Hypothesis/Purpose:Our purpose was to investigate subjective outcomes and complication profile of consecutive cohorts under age 18 undergoing MPFL repair or MPFL reconstruction. Our hypothesis was that the MPFL reconstruction group would have higher subjective outcome scores and a lower complication profile.Methods:Following IRB approval, a retrospective review of prospectively collected data identified a consecutive cohort of patients undergoing soft tissue stabilization for recurrent patella instability. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. MPFL repair was performed on patients prior to November 2015 and MPFL reconstruction with allograft from December 2015 to present. Patients undergoing concomitant bony realignment procedures were included. Patient reported outcomes (PROs) were collected including PROMIS, KOOS, IKDC, Marx, Tegner, and SANE scores. Complications requiring re-operation (i.e., infection, stiffness, recurrent instability) were recorded. Results were analyzed statistically.Results:The cohort was comprised of 43 patients (53 knees), with 15 males (34.9%), and 28 females (65.1%). The MPFL-Repair cohort had 22 patients (24 knees) and the MPFL-Reconstruction had 25 patients (29 knees). The average age of the MPFL-Repair cohort was 14.82 (range 10.5-17.8) and the average age of the MPFL-Reconstruction group was 15.59 (13.0-17.7). At final follow-up (minimum 6 months), there were no statistically significant differences between cohorts for KOOS Pain (p=0.4126), KOOS symptoms (p=0.7990), KOOS ADL (p=0.4398), KOOS Sport Rec (p=0.3357), KOOS QOL (p=0.8707), Global Physical Health (p=0.9736), Global Mental Health (p=0.1724), Physical Function (p=0.8077), Pain Interference (p=0.9740), Mobility T-Score (p=0.0634), Marx activity score (p=0.0844), Tegner Score (p=0.0752), IKDC (p=0.2646), and SANE score (p=0.0811). Regarding complications requiring re-operation, there was 1 knee in the MPFL-Reconstruction group (3.4%) that required further surgery (1 for fracture) and 9 knees in the MPFL-Iso cohort (37.5%) that required re-operation (1 for fracture, 8 for recurrent instability). The difference in complication rate was statistically significant (p=0.0012).Conclusion:In patients under 18 years old undergoing surgery for refractory patella instability, both MPFL allograft reconstruction and MPFL primary repair demonstrated no difference in subjective outcome scores at midterm follow-up. MPFL primary repair had significantly increased rate of complication requiring re-operation, particularly recurrent patella instability requiring revision to MPFL reconstruction.Tables/Figures:Table 1.1.KOOSSub-scaleSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundADLRepair89.4516.0782.3296.57220.4398Reconstruction92.529.0988.4996.5522PainRepair85.8515.8478.8392.88220.4126Reconstruction89.028.4285.2892.7522SportRepair66.5929.5453.5079.69220.3357Reconstruction73.6416.7066.2381.0422SymptomsRepair81.7316.3574.4888.98220.7990Reconstruction80.6411.3075.6385.6522QOLRepair60.8226.1049.2472.39220.8707Reconstruction61.9418.7953.6170.2722Table 1.2.PROMISSub-scaleSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundGlobal Physical HealthRepair50.3910.3744.4056.38140.9136Reconstruction50.097.1847.1952.9926Global Mental HealthRepair56.738.1152.0561.41140.1724Reconstruction52.2710.4048.0656.4726Pain Interference T-ScoreRepair52.279.6047.1557.38160.9740Reconstruction52.178.2248.8555.4926Physical FunctionT-ScoreRepair47.168.2442.7751.55160.8077Reconstruction47.787.9944.6250.9427MobilityT-TestRepair50.068.9843.1556.9690.0634Reconstruction43.317.1239.0147.6113Table 1.3.OtherVariableSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundMarxRepair7.106.124.249.96200.0844Reconstruction3.685.900.846.5319SANERepair62.7528.5547.5477.96160.0811Reconstruction75.5215.7868.7082.3523TegnerRepair5.213.033.756.67190.0752Reconstruction3.682.002.724.6519IKDCRepair70.0419.6259.5980.50160.2646Reconstruction63.7414.7057.2270.2622

Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population

To comparatively evaluate the clinical outcomes and rates of recurrent instability in young patients with primary medial patellofemoral ligament (MPFL) repair or reconstruction, as well as to assess for radiologic risk factors for worse outcomes. A retrospective review identified all patients with lateral patellar instability who underwent either MPFL repair and/or imbrication or MPFL reconstruction without any additional osseous procedures between 2008 and 2015 at a single center. Demographic variables and preoperative magnetic resonance imaging were analyzed, and Kujala scores were obtained at a minimum 2-year follow-up. Risk factors for worse outcomes were assessed, including the Caton-Deschamps Index (CDI) Insall-Salvati Index, tibial tubercle-trochlear groove distance, and tibial tubercle-posterior cruciate ligament distance. We identified 51 knees with isolated MPFL surgery (reconstruction in 32 andimbrication and/or repair in 19) at a mean of 59.7months' follow-up (range, 24-121months). The overall rate of recurrent dislocations was significantly greater in the repair group (36.9%) versus the reconstruction group (6.3%, P=.01), despite the average CDI being significantly higher in the reconstruction group (1.34 vs 1.23 in repair group, P=.04). No significant difference in the rate of return to baseline activity was found between the groups (77.8% in reconstruction group vs 70% in repair group, P= .62). The average Kujala score showed no significant difference between the repair and reconstruction groups (84.15 ± 14.2 vs 84.83 ± 14.38, P= .72). No imaging measurements were found to be predictive of a worse postoperative Kujala score; however, the average CDI among the MPFL repair failures (1.30 ± 0.05) was significantly higher than among the MPFL repair nonfailures (1.18 ± 0.12, P= .03). MPFL reconstruction may provide improved midterm clinical outcomes and a decreased recurrence rate compared with MPFL repair. Increased patellar height as measured by the CDI may be a risk factor for recurrent patellar instability in patients who undergo isolated MPFL repair. Level III, retrospective comparative study.

Medial Patellofemoral Ligament Repair

Medial patellofemoral ligament repair (MPFL) represents an alternative method of medial soft tissue management in patients with lateral patellar instability. MPFL repair is best indicated in patients with isolated patellar- or femoral-based avulsions, which can be identified on preoperative MRI. MPFL repair technique utilizes small incisions over the site of injury, where sutures anchors are used to repair the residual stump to its anatomic insertion site. Medial reefing, otherwise known as imbrication, is a technique to tighten the medial soft tissues, and is most commonly used as an adjunct to other realignment procedures when mild residual instability remains. Overall, we recommend a systematic and multifactorial approach to patellar instability, with decisions regarding medial soft tissue management based on the MPFL injury pattern on MRI.

Suture Tape Augmentation Repair of the Medial Patellofemoral Ligament

Adolescents with osteochondral loose bodies after a first-time patellar dislocation are most commonly treated with surgical intervention. However, the ideal method of managing a concurrent medial patellofemoral ligament (MPFL) disruption is still unknown. Recent evidence suggests high failure rates are associated with primary MPFL repair. The purpose of this Technical Note is to describe an alternative surgical technique for managing acute first-time patellar dislocations by using high-strength suture augmentation of the MPFL.

Medial Patellofemoral Ligament Repair With Suture Tape Augmentation

The medial patellofemoral ligament (MPFL) is the main restraining force in the first 20° of flexion against lateral patellar displacement and is disrupted after patellar subluxation or dislocation. MPFL reconstruction is frequently performed when conservative management fails and the patient has recurrent patellar dislocations. However, a variety of complications have been reported in the literature with this procedure. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, MPFL repair with suture tape augmentation.

Isolated Medial Patellofemoral Ligament Repair vs Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Population

Medial patellofemoral ligament(MPFL) injuries are common with recurrent lateral patellar instability (LPI), but there is no consensus on the ideal technique for surgical management. The objective of this study was to comparatively evaluate the clinical outcomes and rates of recurrent instability in young patients with isolated MPFL repair or imbrication vs reconstruction.

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.

Medial patellofemoral ligament repair restores stability in pediatric patients when compared to reconstruction

BackgroundPediatric patellar instability has a high recurrence rate with non-operative care, and medial patellofemoral ligament (MPFL) reconstruction has known complications. MPFL repair offers an alternative method to restore patellar stability. This study's purpose was to assess the outcomes of MPFL repair in a pediatric cohort, and to compare these outcomes to a cohort of pediatric patients who underwent MPFL reconstruction. MethodsOne surgeon performed 16 MPFL repairs on pediatric patients for traumatic patellar instability, with an average follow-up of 1.5 years. Age, sex, skeletal maturity, trochlear dysplasia, additional procedures, final range of motion, and complications were recorded. A sub-cohort with >1 dislocation (10 patients) was compared to a historical group (22 patients) with >1 dislocation who underwent allograft MPFL reconstructions by the same surgeon. ResultsTen out of 16 (63%) patients had >1 dislocation event at time of presentation. Thirteen out of 16 (81%) patients had trochlear dysplasia. There were no complications and no recurrent instability in the repair group at last follow-up. Patients in the reconstruction group were older than the repair group (15.6 years vs. 13.0 years, p < 0.05), had lower Caton–Deschamps ratio (1.2 vs. 1.4, p < 0.05), and had lower percentage of additional procedures (59% vs. 100%, p < 0.05). There were three complications in the reconstruction group: two patients with recurrent instability and one patient with patella fracture requiring revision surgery. ConclusionsMPFL repair in pediatric patients resulted in a low risk of recurrent instability with rates comparable or better than that of allograft reconstruction.

Osteotomy of the Tibial Tubercle for Anteromedialization

Patellofemoral instability is a common cause of anterior knee pain, especially in younger and more active patients. Treatment of instability varies considerably depending on the patient's symptoms as well as the cause of the instability. Lateral instability has a particularly broad spectrum of treatment algorithms including patellar taping, arthroscopy, lateral release, medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and osteotomy of the tibial tubercle for realignment. Acute traumatic lateral dislocation is commonly associated with a tear of the MPFL and, therefore, needs to be addressed. However, patients who show lateralization of the tibial tubercle with an increased tibial tubercle–to–trochlear groove distance, tibial tubercle–to–posterior cruciate ligament distance, and Q-angle measurements often display chronic instability even after an MPFL reconstruction. In these cases, an osteotomy of the tibial tubercle is required to establish proper alignment and minimize the risk of recurrence of instability. The objective of this Technical Note is to describe our preferred method to complete a Fulkerson tibial tubercle osteotomy for anteromedialization and treatment of chronic patellar instability.

Return-to-Play Guidelines After Medial Patellofemoral Ligament Surgery for Recurrent Patellar Instability: A Systematic Review

Background: Medial patellofemoral ligament (MPFL) reconstruction and repair continue to gain acceptance as viable treatment options for recurrent patellar instability in patients who wish to return to sports after surgery. Return-to-play guidelines with objective or subjective criteria for athletes after MPFL surgery, however, have not been uniformly defined. Purpose: To determine whether a concise and objective protocol exists that may help athletes return to their sport more safely after MPFL surgery. Study Design: Systematic review. Methods: The clinical evidence for return to play after MPFL reconstruction was evaluated through a systematic review of the literature. Studies that measured outcomes for isolated MPFL surgery with greater than a 12-month follow-up were included in our study. We analyzed each study for a return-to-play timeline, rehabilitation protocol, and any measurements used to determine a safe return to play after surgery. Results: Fifty-three studies met the inclusion criteria, with a total of 1756 patients and 1838 knees. The most commonly cited rehabilitation guidelines included weightbearing restrictions and range of motion restrictions in 90.6% and 84.9% of studies, respectively. Thirty-five of 53 studies (66.0%) included an expected timeline for either return to play or return to full activity. Ten of 53 studies (18.9%) in our analysis included either objective or subjective criteria to determine return to activity within their rehabilitation protocol. Conclusion: Most studies in our analysis utilized time-based criteria for determining return to play after MPFL surgery, while only a minority utilized objective or subjective patient-centric criteria. Further investigation is needed to determine safe and effective guidelines for return to play after MPFL reconstruction and repair.

Medial Patellofemoral Ligament Repair Versus Reconstruction for Recurrent Patellar Instability: Two-Year Results of an Algorithm-Based Approach.

Background:Patellar instability remains a challenging problem for both the patient and surgeon. Medial patellofemoral ligament (MPFL) repair has historically had poor results, and due to this, there is currently a trend toward reconstruction.Purpose/Hypothesis:This study was undertaken to investigate experience with repair versus reconstruction of the MPFL using a multifactorial treatment algorithm approach. Our hypothesis was that there will be no significant difference in outcome scores between patients in the MPFL repair and reconstruction groups.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 24 patients with recurrent (≥2) lateral patellar dislocations were included. All had failed nonoperative treatment for more than 6 months, and all were observed for a minimum of 2 years. First, magnetic resonance imaging (MRI) was used to find the location of the MPFL tear. A tilt test was used to determine whether a lateral retinacular lengthening was required to allow the patella to have neutral tilt. If the MRI showed a tibial tubercle–trochlear groove (TT-TG) distance greater than 20 mm, a tibial tubercle osteotomy (TTO) was recommended. An MPFL reconstruction was performed if the entire ligament was inadequately visualized on MRI or if it was torn from both insertion sites. Failure was defined as recurrent lateral patellar instability after surgery. As a secondary outcome measure, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and Tegner score were calculated.Results:All patients were evaluated with a mean follow-up of 51 months (range, 25-79 months). Sixteen patients initially underwent MPFL repair, 8 underwent reconstruction, and 3 also underwent TTO. MPFL reconstructions were performed in all patients who underwent TTO. One MPFL repair was to the anatomic femoral origin and 15 were to the patellar insertion corresponding to the site of tearing on MRI. A lateral retinacular lengthening was performed in 21 patients. There was 1 failure in the repair group (6%) and none in the reconstruction group. However, the patient who failed had a TT-TG distance of 26 mm but refused a TTO. She subsequently underwent revision with a TTO and MPFL reconstruction and did not have any further instability events. There were no significant differences between groups for any of the secondary outcome scores.Conclusion:Using an algorithm-based approach, MPFL repair or reconstruction may lead to clinically acceptable results at 2-year follow-up.

Injuries Requiring Surgery in Dancers Performing High-Demand Dances

Aim:Dancers are professional athletes. Dance injuries resemble sports injuries, however, they push the limits of anatomy and physiology for rightful expression of the esthetics. In this study, we examined a group of dancers and injuries which required surgery to understand the associated factors (age, gender, dexterity, dance style) and also the time to return to their full capacity.Methods:75 members of the Fire of Anatolia professional dance group (55 ethnic folk, 12 modern ballet, 8 Caucasian folk dancers) (mean age: 26.8±5.2; 17-38 years) performers were evaluated between the dates February 2009 and February 2016. The dancers suffered 14 orthopedic injuries requiring surgery during a six-year period. Nine of surgeries (64.2%) were the result of an acute trauma requiring meniscal repair in three due to meniscus tears, ACL reconstruction in two (one of them had to also undergo primary repair of the posterolateral corner of the knee) due to ACL tear, PCL reconstruction in one due to PCL tear, open medial patellofemoral ligament repair in one due to acute patellar dislocation, percutaneous fixation of the scaphoid in one due to scaphoid fracture and an extensor tendon repair of the hand in one due to extensor tendon cut. Five of the surgeries (35.7%) were due to chronic injuries consisting of deep infrapatellar bursitis treated by open bursectomy in one, arthroscopic fat pad resection due to Hoffa’s fat pad impingement in two, and arthroscopic resection of an symptomatic medial plica in two patients.Findings:Fourteen (12 male, 2 female; mean age: 30±5.45, range: 22 to 38) dancers out of 75 members (18.7%) of this high-demand dance group suffered injuries requiring surgery. Twelve (85.8%) of these injuries were at the knee joint and two (14.2%) were in the hand. There was no statistically significant difference between the mean ages of the dancers with and without injuries (p>0.05). Males suffered an injury 8.64 times more than females according to logistic regression analysis (p=0.003).Results:Male dancers are more susceptible to injuries that require surgery when compared to female dancers. All of the operated patients continue with their careers in dancing and arthroscopic surgery does not pose a threat to the career of the dancer. Level of Evidence: Level of evidence III. Retrospective cohort study

Imaging assessment of patellar instability and its treatment in children and adolescents

Transient patellar dislocation is a common entity in children and adolescents, characterized by lateral dislocation of the patella, usually with spontaneous reduction. Many predisposing conditions have been described, including trochlear dysplasia, excessive lateral patellar tilt, patella alta and lateralization of the tibial tuberosity. Associated injuries are bone bruises of the patella and lateral femoral condyle, tears of the medial retinaculum that include the medial patellofemoral ligament (MPFL), tears of the vastus medialis obliquus muscle, injuries of articular cartilage, and intra-articular bodies. Children who are refractory to conservative management, have a large cartilage defect, or are at substantial risk for recurrent dislocations are candidates for surgical procedures to prevent future dislocations. Procedures can include MPFL repair or reconstruction, tibial tubercle repositioning and lateral retinacular release. The purpose of this review is to illustrate the imaging findings of transient patellar dislocation in the acute setting, the normal imaging appearance after surgical intervention, and post-surgical complications.

MPFL Repair for Acute Patella Dislocation

Objectives:To report on the findings of a single surgeon series of MPFL(medial patello-femoral ligament) repair in the treatment of first time patella dislocation.Methods:47 patients with 49 MPFL repairs for first time patella dislocation have been reviewed. All patients had pre-operative x-ray and MRI to define pathology, site of MPFL injury, presence of loose body/bodies, chondral injury etc. All patients underwent acute surgical repair at the site of injury to MPFL, as well as treatment of any secondary pathology. All patients were managed with a similar post-operative protocol of early weight bearing and range of motion utilizing a J-brace. Patients were contacted by phone or returned in person for completion of Kujula scores at time of reporting.Results:40 patients with 42 knees were available for final follow-up. Average follow up period is 3-9 yrs. Average Kujula score 89/100. 3 of 42 recurrent dislocation for rate of 6.1%. 1 deep infection. MPFL rupture site 28/49 at patella (57%), 15/49 at femur (30%), 3/49 both patella and femur (6.1%),1/49 mid-substance (2%), 2/49 not seen on MRI or at surgery ( 4%) Osteochondral loose body 28/49 (57%) 9/49 required additional oft tissue surgeryConclusion:This series describes the location of MPFL injury in first time patella dislocation. In this surgical series there is a high incidence of secondary injury. At 3.9yr follow up this series demonstrates a recurrent dislocation rate of 6.1%.