Proximal Realignment Research Articles

Medial patellofemoral ligament reconstruction appears to be a better treatment than repair, proximal realignment, or conservative management for primary patellar dislocation: A network meta-analysis.

The purpose of this study was to compare the functional outcomes and re-dislocation rates of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, combined proximal realignment (CPR), and conservative management for primary patellar dislocation by conducting a systematic literature search of the available studies. The hypothesis was that MPFL repair and MPFL reconstruction would be better options for treating primary patellar dislocation. Randomized controlled trials or prospective studies of primary patellar dislocation treated with MPFL reconstruction, MPFL repair, CPR, or conservative management were identified from the MEDLINE, EMBASE, and the Cochrane Library databases through December 31, 2021. A total of 626 patients met the prespecified inclusion criteria. The methodological quality of each study was assessed using a risk of bias table, Detsky quality index, and Newcastle-Ottawa Scale. The end-point data collected included comparisons of the mean in functional scores on knee outcomes scales and the number of patients who experienced re-dislocation. A network meta-analysis of the relevant literature was performed to investigate which treatment showed better outcomes. In total, 10 trials were included in this study. There was no statistically significant difference in the subgroup analysis in terms of the functional outcomes among MPFL reconstruction, MPFL repair, CPR, and conservative management. However, MPFL reconstruction showed statistically significantly better outcomes than MPFL repair, CPR, or conservative management in terms of the re-dislocation rate. Additionally, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair even though there was no significant difference (0.24, 95% confidence interval: 0.02-2.91). Using a network meta-analysis, this meta-analysis showed that there was no significant difference in functional outcomes in a subgroup analysis. In re-dislocation subgroup analysis, MPFL repair and MPFL reconstruction produced significantly better results than other treatments. Also, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair.

A preliminary study of proximal realignment combination surgery in the treatment of adolescent habitual patellar dislocation

ObjectiveA combination of lateral soft tissue release, medial soft tissue contraction, vastus medialis anterior placement, medial patellofemoral ligament reconstruction, and rectus femoris insertion reconstruction are introduced in the treatment of habitual patellar dislocation in adolescents.MethodsA retrospective analysis was performed on 12 patients (17 knees) with habitual patellar dislocation and unclosed epiphyses who underwent surgical treatment at the First Hospital of Jilin University from May 2017 to November 2021. The Lysholm scores and Q angle were collected preoperatively and at final follow-up and were compared.ResultsTwelve patients (4 boys and 8 girls) aged 10–15 years were retrospectively analysed, who followed up for an average of 21 months (5–48 months). The range of motion of the knee joint returned to normal in all patients, and no cases of complications including surgical site infection, joint stiffness, or patellar re-dislocation occurred. The mean Lysholm scores and Q angles improved from 73.9, and 19.6° preoperatively to 91.7, and 13.9° at the final follow-up, respectively.ConclusionThe preliminary effect of the combination surgery for habitual patellar dislocation in adolescents was satisfactory.

Insall proximal realignment with/without tibial tubercle osteotomy for recurrent patellar instability yields acceptable medium- to long-term results but risk of osteoarthritis progression is considerable

PurposeThe purpose of this study was to evaluate clinical and radiological results in patients operated for recurrent patellar instability with a surgical approach consisting of Insall proximal realignment with/without tibial tubercle osteotomy (TTO).MethodsPatients that underwent surgery for recurrent patellar instability at one centre with a uniform technique between 2004 and 2020 were included. Eligible patients were assessed by clinical examination and the disease-specific Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0). Pre- and postoperative radiographs were analysed for patellofemoral osteoarthritis (OA) according to Iwano. Preoperative Magnetic Resonance Imaging (MRI) and radiographs were analysed for anatomical risk factors for patellar instability. Student t-test, chi-square test and ANOVA-analyses were used to investigate whether anatomical risk factors and/or patient characteristics could predict an inferior outcome.ResultsForty-six patients (47 knees) were included at a mean follow-up time of 6.6 years (SD 4.6; range 1–17). Mean BPII 2.0 score was 60.4 (SD 18.4; range 26–98), and 10.6% (n = 5) had suffered a postoperative redislocation. Progression to evident patellofemoral OA was seen in 15% of the patients (p < 0.05). The presence of pathoanatomic risk factors did not correlate with recurrent postoperative instability or inferior BPII 2.0 score at the final evaluation.ConclusionPatients treated with the current approach reported acceptable medium- to long-term results, but the risk of patellofemoral OA progression is significant. These findings add to the knowledge of expected outcomes after procedures involving Insall proximal realignment, and can guide clinical decision making for surgeons using similar methods.Level of evidenceLevel IV, case series.

ISOLATED MPFL RECONSTRUCTION VS. TIBIAL TUBERCLE OSTEOTOMY AND MEDIAL RETINACULAR PLICATION FOR RECURRENT PATELLAR INSTABILITY: A MATCHED, COHORT ANALYSIS OF CLINICAL OUTCOMES COMPARING TWO TECHNIQUES

Background:Historically, the most commonly utilized technique to address recurrent patellofemoral instability (PFI) was a combined proximal and distal realignment, specifically the tibial tubercle osteotomy (TTO) with a proximal medial retinacular plication/reefing/tightening/repair (MRP). Rising interest in the medial patellofemoral ligament reconstruction (MPFLR) over the last decade, now frequently performed as a more powerful isolated proximal realignment procedure, has prompted debate over the optimal technique to treat this common condition.Hypothesis/Purpose:The study hypothesis was that no difference would be detected in recurrent PFI rates or revision surgery rates between patients who underwent TTO-MRP vs. MPFLR.Methods:With cohorts derived from a large, single-center PFI database of 523 patients who underwent a variety of stabilization procedures, 114 eligible MPFLR patients were matched to 109 TTO patients based on age, gender, BMI, and TT-TG distance. Propensity score matching was conducted using logistic regression models to produce 1:1 matching, and a caliper of 0.2 standard deviations of the estimated propensity score was used to for the nearest neighbor matching algorithm. Final matching procedure resulted in 84 MPFLR patients and 84 TTO patients. These were compared on demographics and post-operative clinical results.Results:Demographic and radiologic comparisons of the cohorts are shown in Table 1, with the only difference between groups being an expected higher rate of patients with open physes in the MPFLR cohort. Table 2 shows the TTO-MRP group had longer follow up times, but comparable rates of return to sports. The MPFLR group had a higher rate of recurrent instability, but not to a significant degree, and a significantly higher incidence of revision patellar stabilization surgery (p<0.001). The TTO group had a higher rate of additional knee surgery, the majority of which were implant removal for TTO screws.Conclusion:The TTO-MRP shows equivalent or superior results to the MPFLR for treatment of PFI. However, implant removal may be common with TTO, though this may be somewhat technique-dependent. In the current landscape of increasing interest and utilization of MPFLR as an all-encompassing PFI surgery, the influence of distal bony realignment to minimize recurrence should not be underappreciated.Tables/Figures:

Realineamiento Proximal del Mecanismo Extensor en la Luxación Congénita de la Rótula en Niños y Adolescentes

BackgroundCongenital dislocation of the patella (CDP) is a rare condition. The early diagnosis is difficult, as the patella in the newborns is small and also difficult to recognise. The therapeutic approach of this disorder requires the extended and external release of the quadriceps, the forward movement of the internal oblique vastus, and the transfer or hemi-transfer of the extensor compartment. MethodsTo review the functionality of those patients who have received surgical treatment with proximal realignment of the extensor mechanism using Green‘s surgical technique and the one modified by the author. Between the years 2000 and 2015, a total of 15 patients with 20 knees found to have had congenital dislocation of the patella, and had received the abovementioned surgical treatment. ResultsThe post-operative results were evaluated using the Kujala questionnaire, which gave a mean result of 93.8 / 100. DiscussionThe CDP treatment is a challenge, and even more so if it is associated with an idiopathic retraction of the anterior rectus. The clinical and functional results obtained suggest that an anatomic and stable realignment of the patella in the femoral trochlea allows a satisfactory extensor alignment of the quadriceps. This leads to the disappearance its initial flexor action, which allows the gradual elongation of the extensor mechanism during the postoperative phases of rehabilitation. The surgical technique described offers a good alternative for the treatment of this rare congenital disorder of the knee.Level of evidence: IV

Functional outcome analysis for habitual patella instability treatment by MPFL advancement technique

Aim: Evaluation of functional outcome following medial patellofemoral advancement surgical procedure in habitual patellar dislocation.Material and method: Prospective study was conducted in the department of orthopedic surgery at Keshav Porwal multispecialty Hospital, Bhilwara, Rajasthan among 24 patients from January 2018 to January 2020. All cases underwent proximal realignment surgery for habitual patellar dislocation with minimum follow-up of 6 months and maximum follow-up of 24 months. Radiological assessment was done using sulcus angle and congruence angle, pain was assessed with VAS scale.Results: Mean age of the study group was 19.14 years. Among them 58.3%were male and 41.7% were female. Mean pre-operative sulcus angle was 132.06 degree and post-operative was 132.39 degree. Congruence angle pre-operative was 62.86 degree and post-operative was 17.81 degree. VAS score preoperatively and postoperatively were 6.16 and 3.01 respectively. Conclusion: we conclude that following MPFL advancement surgery radiological parameters were brought back to normal anatomical position with painless functional outcome.

105. ALIF generates better correction of the fractional lumbar curve vs posterior instrumentation alone in spinal deformity fusion to the pelvis

BACKGROUND CONTEXT ALIF is a widely accepted strategy to increase lumbar lordosis and improve fusion. It may also help reduce the fractional lumbar curve. Improved fractional curve correction can level the pelvis and facilitate proximal realignment. PURPOSE To determine if the addition of an anterior lumbar interbody fusion (ALIF) to posterolateral fusion results in a more level pelvis by correcting the fractional lumbar curve. STUDY DESIGN/SETTING Retrospective comparative observational cohort. PATIENT SAMPLE Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity. OUTCOME MEASURES Pre- and postop fractional curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence, sacral slope and percent curve correction. METHODS Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity were identified and stratified into patients who had an ALIF in addition to PSF (ALIF+PSF) and those who had a posterior instrumented fusion (PSF) only. Radiographic parameters measured included preop and postop fractional curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence, sacral slope and percent curve correction. RESULTS There were 30 cases in the ALIF+PSF group and 31 in the PSF group. Baseline demographic characteristics of the two groups were similar. Mean preop fractional coronal Cobb (18.2° vs 14.2°, p=0.069), lumbar lordosis (30.9° vs 334.2°, p=0.379) and pelvic parameters were similar between the two groups. Postop lumbar lordosis was similar (48.4° vs 44.1°, p=0.183). Greater fractional coronal curve correction was achieved in the ALIF+PSF group (69%) compared to the PSF group (29%, p CONCLUSIONS There is a greater correction of the fractional curve in the ALIF+PSF group compared with the PSF only group. While this may not be the primary indication for ALIF, it is a benefit that may level the pelvis and facilitate overall deformity correction. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

TO EVALUATE THE OUTCOME FOLLOWING PROXIMAL REALIGNMENT PROCEDURE FOR HABITUAL PATELLAR DISLOCATION: AN ANALYTICAL STUDY.

Aim: to evaluate outcome following proximal realignment procedure in habitual patellar dislocation.&#x0D; Materials and Methods: prospective comparative study was conducted in the Department of Orthopedics Jawaharlal Nehru Medical College, Bhagalpur from jan 2019 to December 2019 among 18 patients who underwent proximal realignment for habitual patellar dislocation with a minimum follow up of 6 months and a maximum follow up of 2 years. Radiological assessment was done by measuring sulcus angle and congruence angle and pain was assessed using VAS scale.&#x0D; Results: mean age of the study population was 18.64 years and 55.6% were male and rests 44.4 were female. Mean pre and post operative sulcus angle (132.46, 132.58) and Congruence angle (62.86, 17.81). Two the cases showed recurrence.&#x0D; Conclusion: we conclude that following proximal realignment procedure for habitual dislocation of patella radiological parameters were brought back to normal. There were no significant changes in sulcus angle.&#x0D; Keywords: patella, habitual dislocation, outcome, proximal realignment

Radiological outcome following proximal realignment procedure for habitual dislocation of patella

Introduction: Instability of the patellofemoral joint may manifest as acute patellar dislocation, recurrent patellar dislocation or subluxation, habitual patellar dislocation or chronic patellar dislocation. Habitual dislocation of patella is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee. We conducted this study to know the radiological outcome following proximal realignment procedure (Campbell procedure) for habitual dislocation of patella. Materials and Methods: The study was conducted from June 2017 to January 2019 with a minimum follow up of 6 months and a maximum follow up of 2 years. Inclusion Criteria: All patients with habitual patellar dislocation, age between 5 to 40 years. Exclusion Criteria: Patient age less than 5 years and aged above > 40 years, past history of knee surgery, acute patellar dislocation and knee effusions. Radiological assessment was done by measuring sulcus angle and congruence angle. Conclusion: we conclude that following proximal realignment procedure (Campbell procedure) for habitual dislocation of patella radiological parameters were brought back to normal. There were no significant changes in sulcus angle. Congruence angle was brought back to normal, which was statistically significant (p Keywords: Habitual dislocation of patella, Campbell procedure, Sulcus angle, Congruence angle.

Surgical treatment of habitual lateral patellar instability by proximal realignment procedure (Campbell technique)

Background: Patellar instability may manifest as acute patellar dislocation, recurrent patellar dislocation or subluxation, habitual patellar dislocation or chronic patellar dislocation. Habitual patellar dislocation is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee. The purpose of this study is to know the functional and radiological outcome following proximal realignment procedure (Campbell technique) for habitual patellar dislocation. Methods: The study was conducted from June 2017 to January 2019 with a minimum follow up of 6 months and a maximum follow up of 2 years. Inclusion Criteria: All patients with habitual patellar dislocation, age between 5 to 40 years. Exclusion Criteria: Patient age less than 5 years and aged above > 40 years, past history of knee surgery, acute patellar dislocation and knee effusions. Radiological assessment was done by measuring sulcus angle and congruence angle. Functional outcome was assessed by Kujala score. Conclusion: Campbell technique (lateral release of tight structures and medial plication of patellar retinaculum) is a safe and effective procedure for treating habitual patellar dislocation. Functional outcome evaluated by Kujala score was good for most of our patient’s. Radiological parameters (sulcus angle and congruence angle) were brought back to normal. There were no significant changes in sulcus angle. Congruence angle was brought back to normal, which was statistically significant (p

Middle-to long-term outcome after medial patellofemoral ligament reconstruction with Insall’s proximal realignment for patellar instability

BackgroundRecently, medial patellofemoral ligament (MPFL) reconstruction has become a common, widely used procedure to treat patellar instability. However, few reports exist on the long-term outcome after MPFL reconstruction. We elucidated the middle- to long-term outcome after MPFL reconstruction with Insall’s proximal realignment. Methods: From 1999 to 2012, 42 knees of 32 patients who underwent MPFL reconstruction with Insall’s proximal realignment were reviewed with a minimum follow-up of five years. Patients who could visit our office and receive some designated examinations were included in this study. The re-dislocation rate and patellar apprehension sign postoperatively were evaluated. The Kujala score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were calculated. We assessed the images using plane x-ray and magnetic resonance imaging (MRI). The tilting angle (TA), congruence angle (CA), and lateral shift ratio (LSR) on the plane x-ray were measured pre- and postoperatively and at final follow-up. Using MRI, osteochondral lesions at the patellofemoral joint were evaluated. ResultsA total of 20 knees of 15 patients (two male, 13 female) who could visit our office were studied. The follow-up rate was 47.6%. The mean age at operation was 19.9 (11–41) years and mean follow-up was 123 (60–215) months. One knee (5.5%) had a history of postoperative subluxation, and five (25%) had a positive apprehension sign. The mean Kujala score significantly improved from 65.5 to 86.1 points (P < 0.05). The mean KOOS (symptom, pain, activities of daily living [ADL], sports, quality of life [QOL]) was 74.4, 92.4, 97.3, 84.1, and 73.2 points, respectively, at final follow-up. On the plane x-ray, patellofemoral alignment was improved postoperatively, and this improvement was maintained at final follow-up. On MRI, in five of 20 cases, the patellofemoral osteoarthritic change was observed at final follow-up. However, in four of these five knees with severe osteochondral lesions, osteochondral fixation or transplantation surgery had been performed. Only one of the remaining 15 knees had a patellofemoral osteoarthritic change observed at final follow-up. ConclusionMiddle- to long-term outcome after MPFL reconstruction with Insall’s proximal realignment at our institution was evaluated, and good clinical results were observed. Most patients who did not have a severe cartilage lesion preoperatively did not develop osteoarthritic change.

The Outcomes of Isolated Distal Realignment Procedures in Patellofemoral Instability: A Systematic Review and Meta-analysis.

Distal realignment procedures are now commonly performed routinely with proximal realignment procedures. Despite so, only a limited number of publications exist that have looked into the efficacy of isolated distal realignment procedures, and whether there is indeed a need for routine proximal realignment procedures to be added to the distal realignment procedures. The current systematic review and meta-analysis aims to evaluate the outcomes of isolated distal realignment procedures in the management of patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRSIMA) guidelines. All studies that reported the outcomes of isolated distal realignment procedures for patellofemoral instability were included. A total of six publications were included, with 347 knees. All studies consistently reported a decrease in the rates of patellofemoral instability or maltracking (odds ratio [OR]: < 0.01; 95% confidence interval [CI]: < 0.01-0.01) and an increase in the odds of having a good outcome (OR: 0.01; 95% CI: < 0.01-0.02) after distal realignment procedures. A total of 24 out of 306 patients (7.8%) had postoperative instability or maltracking, and a total of 220 out of 303 patients (72.6%) were rated to have good or excellent outcomes postoperatively. Isolated distal realignment procedures can lead to good outcomes when used in the management of patellofemoral instability. These include a significantly decreased rate of patellofemoral instability or maltracking and a significantly increased number of patients with excellent or good outcomes postoperatively. Comparisons between patients with and without additional proximal realignment procedures suggest that additional proximal realignment procedures do not definitely improve the outcomes of distal realignment procedures and, therefore, should not be routinely performed in all patients undergoing distal realignment procedures. The Level of Evidence for this study is IV.

Medial patellofemoral ligament reconstruction fails to correct mild patella alta in cases of patellofemoral instability-a case-control study.

Medial patellofemoral ligament reconstruction (MPFL-R) is the gold standard in patella soft tissue surgery for patellofemoral instability. Although claimed, recent reports indicate that MPFL-R may fail to distalize the patella in mild cases of patella alta. The present study is a retrospective case-control study to compare radiographic patella height between MPFL-R and historical Insall's proximal realignment (IPR) pre- and post-operatively with respect to distalization and assess redislocation rates at a mid-term follow-up. Sixty-four patients were age/sex matched (1:1), yielding 32 patients for group 1 MPFL-R (cases) and 32 patients for group 2 IPR (controls). Insall-Salvati, Blackburne-Peel and Caton-Deschamps indices were analyzed for differences pre- and post-operatively. An additional inter-rater reliability analysis was performed by means of intra-class correlation (ICC). Redislocation rates were considered as treatment failures in this study. ICC was excellent for all three patella indices. MPFL-R failed to show significant differences if compared to IPR with respect to distalization in mild stages of patella alta. Moreover, redislocation rates significantly favored MPFL-R (3.1%) over IPR (12.5%; p < 0.0001). MPFL-R has become a popular option to restore native patellofemoral biomechanics after ligament rupture. However, the procedure's potential to correct concomitant patella alta should not be overestimated and indications considered carefully.

Solitary Trochleoplasty for Treatment of Recurrent Patellar Dislocation.

Solitary trochleoplasty for recurrent patellar dislocation offers a unique benefit in that it addresses the most important factor in patellar instability: the trochlear dysplasia. The trochlea is visualized through a lateral arthrotomy of the knee joint. An osteochondral layer is peeled off with curved chisels and extended into the intercondylar notch. A triangular bone block is removed from the subchondral bone to form the new groove. A new groove is begun with a chisel and smoothed with a high-speed burr. Also, the osteochondral layer is thinned out and fixed back transosseously in the new groove with 2 Vicryl (polyglactin) bands. The bone block is used to lengthen the lateral condyle by placing it under the osteochondral layer at the proximal extension of the lateral femoral condyle with an overlap of 1 cm. Nonsurgical alternatives include a knee or patellar brace, taping of the patella, and physiotherapy for strengthening of the vastus medialis obliquus of the quadriceps muscle. Surgical alternatives include reconstruction of the medial patellofemoral ligament; several femoral and tibial osteotomies, such as rotational osteotomies of the femur and tibia or medialization of the tibial tuberosity; and several soft-tissue interventions, such as medial reefing, relocation of the patellar tendon as described by Goldthwait1, and proximal realignments according to the method described by Insall et al.2 or Green et al.3. Most patients with recurrent patellar dislocation have a dysplastic trochlea4, which is considered to be the primary reason for a recurrence. While interventions such as reconstruction of the medial patellofemoral ligament or femoral and tibial osteotomies also provide stability of the patella, they do not change the most essential factor of the instability-the trochlear dysplasia. The trochleoplasty addresses this underlying condition and reshapes the trochlea.

MRI findings associated with medial patellofemoral capsuloligamentous plication.

To review the MRI appearance of medial patellofemoral capsuloligamentous plication (also known as reefing or imbrication) for proximal patellar realignment in patients with patellofemoral instability. Retrospective analysis of our surgical and PACS databases identified cases of medial plication performed between June 2011 and July 2016. Pre- and postoperative MRI characteristics were reviewed. Correlation was made with operative reports and clinical records to define postoperative appearances on MRI. Forty-one patients underwent medial plication during the study period; 29 were excluded owing to a lack of postoperative imaging. Ultimately, 12 knees were included in 11 patients who had postoperative MRI studies available (8 women and 3 men, mean age 27.3 ± 10.2years). Ten (83%) of the surgeries were performed open and 2 (17%) arthroscopically. There were differences in the post-surgical MRI appearance of medial plications carried out after surgery using the open and arthroscopic techniques. The open technique produces a "heaped up" distal vastus medialis obliquus (VMO) with centralized patellar insertion (100%), which was absent in the case of arthroscopic plication, where subtle medial retinaculum thickening was demonstrated without alteration of its patellar insertion. The mean postoperative lateral patellar and patellofemoral congruence angles measured 2.5° ± 5.6° and 12.4° ± 19.9° respectively. A significant association was found regarding change in patellofemoral alignment (p = 0.018 and p = 0.004 respectively). The MRI appearance of medial plication is not well described in the radiology literature; radiologists should be familiar with anticipated post-plication findings to avoid potential confusion for pathology and allow more accurate interpretation of postoperative imaging findings from this common surgery.

Pigmented villonodular synovitis in pediatric population: review of literature and a case report

BackgroundPigmented villonodular synovitis (PVNS) is a rare proliferative process in children that mostly affects the knee joint.Case PresentationThe study follows the case of a 3-year-old boy presenting recurrent patellar dislocation and PVNS. Due to symptoms such as chronic arthritis, he had been taking prednisolone and methotrexate for 6 months before receiving a definitive diagnosis. After a period of showing no improvements from his treatment, he was referred to our center and was diagnosed with local PVNS using magnetic resonance imaging (MRI). The patient was treated for his patellar dislocation by way of open synovectomy, lateral retinacular release, and a proximal realignment procedure, with no recurrence after a 24-month follow-up.ConclusionPVNS may appear with symptoms resembling juvenile idiopathic arthritis, thus the disease should be considered in differential diagnosis of any inflammatory arthritis in children. PVNS may also cause mechanical symptoms such as patellar dislocation. In addition to synovectomy, a realignment procedure can be a useful method of treatment.

Surgical treatment of symptomatic patellofemoral malalignment: Do we need an ideal patellofemoral congruency to solve the symptoms?

Background/Aim. The aim of this prospective nonrandomized study was to test functional results of different surgical strategies in the operative treatment of symptomatic patellofemoral malalignment. Our hypothesis was that immediate extensive surgery does not have serious advantage comparing to ?step by step? procedure, regarding the main symptoms and functional end result. We wanted to check whether obtaining ideal surgical patellofemoral congruency is an essential prerequisite for subsidence of the major symptoms of patellofemoral malalignment. Methods. The study included 35 patients with patellofemoral malalignment who had persistant major symptoms: patellar pain and slipping, 3 months after nonoperative treatment. Divided into three groups, they all underwent the realignment surgery, but in different extent and sequence: immediate extensive surgery, step by step surgery, and only proximal realignment. Their overall functional scores as well as major symptoms were assessed at the beginning, after the surgery, and during the 3-years follow-up period and then, compared at the end. Results. There was no significant difference in the functional results among the groups, neither at the beginning (p = 0.1318) nor at the end of the study (p = 0.3996), but the results at the beginning compared to those at the end of the study showed a statistically significant difference in all three groups (p1 = 0.005062; p2 = 0.011719; p3 = 0.000352). The same result was in regard to the major symptoms. Conclusion. The study confirmed that insisting on immediate extensive surgery in order to achieve precise and complete congruency of the patellofemoral joint, did not prove its advantage over the less invasive, individual surgical approach concerning functional scores and major symptoms.

Second Generation Autologous Chondrocyte Implantation in the Patella: Improved Pain Relief and Functional Outcomes among U.S. Army Servicemembers

Objectives:To evaluate the functional outcomes of autologous chondrocyte implantation (ACI) for high-grade patellofemoral chondral defects in a predominately young, high-demand military demographic.Methods:We conducted a retrospective review of all United States military and Tricare beneficiaries undergoing ACI for Outerbridge grade III or IV patellofemoral chondral defects at a two high-volume military medical centers between 2007 and 2014. Second generation surgical technique was performed using autologous cultured chondrocytes (Vericel, Inc; Boston, MA) secured with a type I/III collagen bilayer membrane. Inclusion criteria required minimum two-year surveillance, although patients with knee-related medical discharge were also included to limit non-responder bias. Exclusion criteria were applied to individuals with predominately condylar involvement, periosteal patch coverage, and/or procedure miscoding Demographic information, surgical characteristics, and clinical outcomes were extracted from the electronic medical record. Averages were calculated with standard deviations (SD). Univariate analysis was used to determine significant independent predictors of surgical failure, which was defined as revision chondral procedure or conversion to arthroplasty. Relative risk was quantified with use of odds ratios (OR) with 95% confidence intervals (95% CI).Results:A total 57 patients with 58 knees were identified at average 2.13 year follow-up within the military health care system. The median age was 33.8 years (range, 20.3 to 49.9). Males comprised 77% of patients (n=44), and 93% (n=53) were active duty military status. Mean patient body mass index (BMI) was 30.3 kg/m2, tobacco use was documented in at least 19.3% (n=11), and only one patient had failed prior marrow stimulation procedure. The average lesion size for ACI was 502 mm2 (SD 318; range, 121-1600 mm2) and most defects were based on patella (91.3%). The average tibial tubercle-trochlear groove (TT-TG) distance was 13.9 mm (SD 3.5), and nearly all knees underwent concomitant anteromedializing or offloading tibial tubercle osteotomy (n=56; 97%). Additionally, only three patients required proximal realignment procedure. Only 1 patient (1.7%) required revision chondral procedure, and there were no cases of graft site hypertrophy or conversion to knee arthroplasty. With a “high” or “severe” average patient-reported pain level (86%), the average postoperative visual analog scale (VAS) was 2.3 (SD 2.2; median, 2) at final follow-up. At an average of 1.9 years postoperatively, 14 patients (24.6%) underwent medical discharge due to reported persistent, rate-limiting knee pain, although the average patient-reported VAS was 3 (SD 2.3; range, 0 to 6). No demographic or surgical variables were significantly associated with subsequent adverse clinical outcome (p>0.05).Conclusion:For patellofemoral chondral defects without failed primary procedure, second generation ACI can successful decrease patient-reported anterior knee pain among highly-active and athletic subsets. Approximately 75% of patients resumed modified military duty or preoperative level of function at short-term follow-up, and only 2% underwent revision. Knee related medical discharge occurred in nearly a quarter of patients, but did not preclude significant pain relief or return to lower demand activities.

Anteromedializing Tibial Tubercle Osteotomy for Patellofemoral Instability: Occupational and Functional Outcomes in U.S. Military Service Members.

This article sought to determine rates for return to work, pain relief, and recurrent patellofemoral instability for military service members undergoing tibial tubercle osteotomy (TTO) for persistent lateral patellar subluxation or dislocation. Patient demographic and surgical variables were isolated from the medical records of active duty service members with at least 2 years of postoperative follow-up, and correlated with return to work, pain improvement, recurrent patellofemoral instability, and perioperative complications. There were 51 service members (58 primary TTOs) with an average follow-up of 3.3 (range, 2.0-6.7) years. Service members had an average of 2.8 (1-12) instability events preoperatively. At a minimum of 2 years postoperatively, 41 (80%) military service members returned to full active duty service. Among the 58 TTOs, there was a 46% improvement in the patient-reported visual analog score from 4.1 to 2.2 (p < 0001). The postoperative recurrent instability rates were patellar dislocation (5.1%) and patellar subluxation (15.5%). Concomitant proximal realignment was performed in 48% of cases, which did not affect return to service, postoperative patellar instability events, or pain improvement (p > 0.05). The overall complication rate was 10%. Postoperative tibial fractures occurred in 6.9% of TTOs. At short- to mid-term follow-up, 80% of service members undergoing TTO for patellofemoral instability returned to military duty with significant improvement in pain scores and a moderate perioperative complication and postoperative instability rate. This study is a level IV therapeutic case series.

Arthroscopic assessment of patellofemoral tracking predicts patellar instability

Objectives:Surgical management of patellar instability includes proximal realignment procedure such as MPFL reconstruction. The decision to add a distal realignment procedure of tibial tubercle transfer is based on severity of patellar instability judged on either TTTG distance or arthroscopic patellofemoral tracking. We set out to validate our use of arthroscopic patellofemoral tracking for patellar instability management algorithm by analyzing its reproducibility and whether it correlates with patellar instability.Methods:A prospective observational study was carried out at Perth Orthopaedic and Sports Medicine Centre. Patient clinical presentations were divided into three groups - patellofemoral instability, patellofemoral pain, and no patellofemoral symptoms. Standard technique included low flow arthroscopy with single anterolateral viewing portal. Height of the fluid bag and presence of a knee holder was recorded. Knee flexion angle where patella first centrally engages in the trochlear groove was defined as Patellofemoral Congruent Angle (PCA). PCA was estimated by the primary surgeon and the angle was confirmed using a sterile goniometer. A second surgeon, blinded to the initial assessment, then repeated the measurements. Surgeon estimation error, interobserver reliability, and correlation with clinical presentation was analysed.Results:57 knees were assessed for interobserver reliability. Intra-class correlation was 0.994 between surgeon’s estimate and goniometer reading. Intra-class correlation was 0.992 between the two surgeon’s readings suggesting a very high correlation. 157 patients had their PCA recorded and compared with their diagnosis. Mean PCA was 40 degrees in normal patients, and 118 degrees in patellar instability (p-value <0.001).Conclusion:Arthroscopic assessment of patellofemoral tracking is reproducible and correlates with patellar instability. A cut-off value of 40 degrees is recommended to differentiate normal tracking from abnormal.