Recurrent Dislocation Research Articles

Acute patellar dislocation: how skeletal maturity affects patterns of injury.

The main objective of this study was to understand the role of skeletal maturity in the different patterns of osteochondral and ligamentous injuries after an acute lateral patellar dislocation. Two radiologists independently reviewed MRIs of 212 knees performed after an acute lateral patellar dislocation to evaluate the presence of high-grade patellar osteochondral injury, femoral osteochondral injury, and medial patellofemoral ligament injury. The association of skeletal maturity (indicated by a closed distal femoral physis), age, sex, and first-time versus recurrent dislocation with each of these various lesions was analyzed using Chi-square or T test, and multivariable logistic regression with estimation of odds ratios (OR). Skeletal maturity was significantly associated with high-grade patellar osteochondral injury [OR=2.72 (95% CI 1.00, 7.36); p=0.049] and femoral-side MPFL tear [OR=2.34 (95% CI 1.05, 5.25); p=0.039]. Skeletal immaturity was significantly associated with patellar-side MPFL tear [OR=0.35 (95% CI 0.14, 0.90); p=0.029]. Patterns of injury to the patella and medial patellofemoral ligament vary notably between the skeletally immature and mature, and these variations may be explained by the inherent weakness of the patellar secondary physis.

Soft Tissue Lengthening for Flexion Dislocation of Patella.

Obligatory dislocation of the patella (also known as habitual dislocation) is a rare subset of patellofemoral instability in which the patella dislocates every time the knee is flexed. The problem arises due to contracture of the quadriceps muscles. Soft tissue lengthening procedures such as quadriceps tendon lengthening are the mainstay of treatment, in contrast to medial patellofemoral reconstruction (MPFL-R) for the more common recurrent lateral patellar dislocation. The current review explores the existing literature surrounding the pathophysiology and treatment strategies for this unique cause of knee instability. Flexion dislocation of the knee often presents in children when they begin to walk. It is also termed obligatory or habitual because the patella dislocates laterally with each flexion and extension cycle of the knee. In contrast to other forms of patellar dislocation, the displacement is painless in obligatory dislocation. Likewise, the underlying biomechanical cause of this issue is related to contracture of tissues lateral to the patella rather than disruption of medial soft tissues as seen in recurrent/traumatic dislocation or subluxation of the patella. A number of procedures have been described for management of obligatory dislocation of the patella, with the general consensus that a combination of procedures including release/lengthening of the proximal lateral soft tissues as a critical component for a successful outcome. Soft tissue release/lengthening has been performed for over 50years to treat obligatory dislocation of the patella. This procedure must be used in combination with other proximal and distal reconstructive with careful intraoperative assessment of knee flexion and patellar tracking for satisfactory outcomes. Further research using standardized outcome measures is needed to identify the optimal step-wise approach in treatment of obligatory patellar dislocation.

Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions.

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success. To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]). Case-control study; Level of evidence, 3. The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm. Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss. Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Functional and Sport-Specific Outcome Following Traumatic First-Time Shoulder Dislocation and Arthroscopic Surgical Repair in Rock Climbers.

Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population. In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d'Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score. The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17-61] y; data presented as mean±SD [range]) was assessed 53±29 (12-103) mo after surgery. The postoperative Constant Murley score was 95±8 (67-100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up. Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system.

Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation. Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging. At a mean follow-up of 28months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P ＜ .001), the Rowe score, improved from 25.3 to 89.1 points (P<.001), the Subjective Shoulder Value improved from 31% to 87% (P<.001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P ＜ .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6%±4.5%) increased significantly immediately after surgery to 116.5%±9.6% (P ＜ .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2%±7.1%) (P ＜ .001). The glenoid surface area appeared to decrease serially when compared between the first 6months and 12months postoperatively, while there was no significant interval change between 12 and 24months postoperatively. Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.

Correlation between glenoid bone structure and recurrent anterior dislocation of the shoulder joint.

The aim of the study was to investigate the anatomical characteristics and symmetry of the bilateral glenoid structures of Chinese people and to explore the relationship between the glenoid bone structure and recurrent anterior dislocation. The control group included 131 individuals with no history of shoulder dislocation. The dislocation group consisted of 131 patients with a history of unilateral shoulder dislocation. All subjects underwent computed tomography scans. Glenoid shape (pear-shaped, inverted comma-shaped, oval-shaped), width, height, depth, version angle, area, maximum fitting circle area and volume were measured. There was no significant difference in normal bilateral glenoid of Chinese people (p > 0.05). There were statistically significant differences in depth, height to width ratio, maximum fitting circle area and shape between the dislocation and control groups (p < 0.05). Regression analyses showed that the glenoid depth (odds ratio [OR] 0.48; p < 0.01), the glenoid height to width ratio (OR 28.61; p < 0.01), the glenoid maximum fitting circle area (OR 1.01; p < 0.01) and the glenoid shape (p <0.05; pear-shaped OR 0.432; inverted comma-shaped OR 0.954) were associated with anterior shoulder instability. Pear-shaped and inverted comma-shaped glenoid had lower risk of recurrent anterior shoulder dislocation compared to oval glenoid. Receiver operating characteristic curve analysis showed that individuals with anterior shoulder instability had smaller glenoid depth and larger height to width ratio and the glenoid maximum fitting circle area compared with the control group. The normal bilateral glenoids of Chinese people are basically symmetrical. The glenoid shape, depth, height to width ratio and maximum fitting circle area are risk factors for recurrent anterior shoulder dislocation. Evaluation of the glenoid bone structure enables more accurate prediction of the risk of recurrent shoulder dislocation.

The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years

The popularity of team handball is increasing with over 10 million children playing this overhead, throwing and collision sport with highest demands on the shoulder joint. Due to the risk for recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball. We included 20 shoulders retrospectively (18 players/17 males/mean age 22.9 years, range 17-35 years; minimum/mean follow-up: 2/6.6 years) operated on by three expert surgeons (2011-2020) with Walch's LP-technique. Preoperative hyperlaxity (25%/n=5), affected throwing arm (55%/n=11), position (backcourt, winger, goalkeeper: 22% each; full back, pivot: 17% each), >2 dislocations prior (20%/n=4), >10 dislocations (5%/n=1), previous failed Bankart/HAGL repair (10%/n=2) and large Hill-Sachs lesions (HSL: 20%/n=4) were documented. Clinical and radiographic outcomes, visual analogue scale (VAS), subjective shoulder value (SSV), Walch-Duplay (WDS), Rowe score (RS) and return to sports (RTS) parameter were recorded. RTS was 85% (n=17/20), RTS to same-level 80% (n=16/20), RTS with no throwing pain 73% (n=8/11), time to training with ball: 3.2/12 and to competition 4.9/12. The mean RS, WDS and SSV were 90, 88, 89 % respectively. Shoulder symptoms lead to giving up handball in 2 cases (10%). One player (5%) stopped for other reasons. One recurrent dislocation (5%) was recorded (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in one goalkeeper (5%). Four shoulders showed residual pain (20%) relieved in one by screw removal. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%/one large HSL) and one goal keeper (5%/large HSL; >10 dislocations prior), all three >30years of age. Bone block positioning was correct (no lateral overhang) in all shoulders. One shoulder (5%) showed mild arthritic changes at final follow-up (>10 dislocations, large HSL). The open Latarjet-Patte is consistent in providing shoulder stability combined with return to throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, with large HSL or shoulders at age >30 years may have an increased risk for persistent symptoms.

Expression of Apelin in Rotator Cuff Tears and Examination of Its Regulatory Mechanism: A Translational Study.

Inflammatory mediators play important roles in the pain associated with rotator cuff tears (RCTs), but their underlying mechanisms are unclear. Apelin, a neuropeptide, is upregulated under inflammatory conditions and possibly contributes to pain induced by rotator cuff tears. This translational study aimed to examine apelin expression and regulation by tumor necrosis factor alpha (TNF-α) in patients with RCT and in rat RCT models. Synovial tissues were harvested from the glenohumeral joints of the shoulders in 46 patients who underwent arthroscopic Bankart repair for recurrent shoulder dislocations (RSDs) or arthroscopic rotator cuff repair for RCTs. The harvested tissues were extracted and processed by reverse transcriptase-polymerase chain reaction (RT-PCR). Rats underwent sham or RCT surgery; the rotator cuff tissues were extracted 1, 7, 14, 28, and 56 days after surgery and analyzed for mRNA expression levels of the TNF-α and apelin using RT-PCR. The cultured rotator cuff cells (RCCs) were stimulated with TNF-α to examine their role in the regulation of apelin expression. Apelin expression was higher in the RCT group than in the RSD group and significantly correlated with pain intensity. In rats, the expression was also higher in RCT. Apelin expression significantly increased during the acute and chronic phases in rats. In cultured RCCs, apelin mRNA levels significantly increased after TNF-α stimulation. Apelin levels were regulated by TNF-α and were highly expressed in patients with RCT and rats in RCT models. Thus, apelin may be a new pain management target for RCTs.

Autologous Blood Injections in Temporomandibular Hypermobility: A Systematic Review.

The injection of autologous blood (AB) is one of the methods of treatment of recurrent dislocations in the temporomandibular joints (TMJs). Due to the low invasiveness of this technique, it is reasonable to evaluate it in accordance with the standards of evidence-based medicine. The purpose of this systematic review is to identify primary studies on AB injection for the treatment of TMJ hypermobility and assess the therapy for effectiveness. This systematic review was conducted in accordance with the current "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. Controlled randomized trials comparing dislocation episode rates, range of motion in the TMJ, or articular pain intensity were adopted as the eligibility criteria. Final searches were conducted on 11 June 2023 using Bielefeld Academic Search Engine, Elsevier Scopus, and the National Library of Medicine: PubMed. Trials were assessed using the "Oxford Center for Evidence-Based Medicine 2011 Levels of Evidence" scale and "A revised Cochrane risk-of-bias tool for randomized trials". The results of the individual studies were tabulated, syntheses were illustrated in graphs. Twenty two studies involving 982 patients were included in the qualitative analysis, of which seven studies involving 390 patients were subject to quantitative analysis. None of the included randomized controlled trials presented a high risk of bias, 75% of them raised some concerns. In a three-month observation, administration of AB was more efficient in limiting temporomandibular dislocations than hypertonic dextrose (1 study, 32 patients, relative risk = 0.33, odds ratio = 0.29) and no difference in outcomes was observed between intracavitary and pericapsular administration compared to pericapsular injection alone (2 studies, 70 patients, relative risk = 1.00, odds ratio = 1.00). Injections of AB into the temporomandibular joints are effective in preventing further TMJ dislocation episodes in 75-94% of patients. This study received no funding.

Different Modalities in Management of Recurrent Patellar Dislocation

Background Patellar instability is a complex pathoanatomical phenomenon that requires an intricate understanding in order to properly treat patients. Often, the etiology of this entity is multifactorial, and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. Objective To review the currently available different modalities for management of recurrent patellar dislocation. This Review will analyze results concerned with Patellar instability to reach the most efficient modality that gives the best results. Material and Methods This systematic review study based on inclusion and exclusion criteria conducted to evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications. This systematic review demonstrates that MPFL surgery for recurrent patellar dislocation isolated or in combination with other procedures results in a significant improvement in Kujala scores, a low redislocation rate, and an acceptable complication rate. Despite this, there is no consensus on indications for MPFL reconstruction, graft type, surgical technique, and rehabilitation program. The inclusion criteria for future studies were highly important, and consensus agreement within an expert panel should be sought prior to undertaking such a study. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Results Several fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction. However, the optimal management of patients with recurrent patellar dislocation remains controversial. This short-term study showed that after MPFL reconstruction (suture anchors or transosseous sutures), patellar stability could be restored. And no significant differences in outcome scores were observed between patients in the transosseous suture and suture anchor groups. Conclusion Evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications.

C-Arm Guidance During Thin Flap Arthroscopic Trochleoplasty for Chronic Patellar Instability

The purpose of this paper is to provide a complete Technical Note for our treatment of choice for recurrent patellar dislocation in cases of trochlear dysplasia, especially in patients with types B and D trochlear dysplasia according to the Dejour classification. Different surgical procedures have been reported for the treatment of recurrent patellar instability. One of the most important anatomic factors to address when treating a recurrent patella dislocation is trochlear dysplasia. Few types of open trochleoplasty have been classically described to treat a dysplastic trochlea. However, in recent years, arthroscopic techniques have been reported to reduce invasiveness and complications as well as to improve accuracy and clinical outcomes. In this technique is described an arthroscopic thin-flap tracheoplasty with the use of C-arm guidance in order to precisely control the bone resection and to verify intraoperatively the disappearance of the radiologic landmarks used for diagnosis and classification of the dysplasia. The advantage of this technique is the precision in removal of the supratrochlear spur and bump, the accurate and delicate reshaping of the sulcus with preservation of cartilage vitality, combined with increased reproducibility and safety.

Medium to long-term outcomes of medial patellofemoral ligament reconstruction using the superficial quadriceps versus a hamstring autograft in patellar instability patients

Medial patellofemoral ligament (MPFL) reconstruction is a standard procedure in patellar dislocation patients. Superficial quadriceps autografts (QA) and hamstring autografts (HA) are popular graft choices in MPFL reconstruction with the lack of directly compared clinical studies between both methods. A total of 43 patellar instability patients, who underwent QA and HA for patellar stabilization at a specified center between 2012 and 2021, were retrospectively reviewed. 21 QA and 22 HA patients were 52.4% of males and 47.6% females with a median age of 25 years (range 12–58) in the QA group, while 63.6% were females with a median age of 21 years (range 14–58) in the HA group. The mean follow-up period was 46.9 months (range 24–77) in QA and 61 months (range 24–100) in the HA group. At the final follow-up, no complications were observed with either technique. No patients presented with recurrent dislocations after surgery. There was no statistically significant difference in postoperative mean Kujala scores (QA = 94.9+/− 4.1 and HA = 94.2+/− 8.0, p = 0.73) or the mean Lysholm scores (QA = 94.1+/− 5.0 and HA = 93.2+/− 7.0, p = 0.61).

"Considerations on Recurrent Patella Dislocation in the Adolescent Athlete"

"Considerations on Recurrent Patella Dislocation in the Adolescent Athlete"

Influence of the quadriceps muscles on the patellofemoral contact in patients with low flexion patellofemoral instability after MPFL reconstruction

MPFL reconstruction represents one of the most important surgical treatment options for recurrent patellar dislocations at low flexion angles associated with low flexion patellofemoral instability. Nevertheless, the role of quadriceps muscles in patients with patellofemoral instability before and after patellofemoral stabilization using MPFL reconstruction has not been fully elucidated. The present study investigates the influence of quadriceps muscles on the patellofemoral contact in patients with low flexion patellofemoral instability (PFI) before and after surgical patellofemoral stabilization using MPFL reconstruction using 3 T MRI datasets in early degrees of flexion (0-30°). In this prospective cohort study, 15patients with low flexion PFI before and after MPFL reconstruction and 15subjects with healthy knee joints were studied using dynamic MRI scans. MRI scans were performed in acustom-made pneumatic knee loading device to determine the patellofemoral cartilage contact area (CCA) with and without quadriceps activation (50 N). Comparative measurements were performed using 3D cartilage and bone meshes in 0-30°knee flexion in the patients with patellofemoral instability preoperatively and postoperatively. The preoperative patellofemoral CCA of patients with low flexion PFI was 67.3 ± 47.3 mm2 in 0°flexion, 118.9 ± 56.6 mm2 in 15°flexion, and 267.6 ± 96.1 mm2 in 30°flexion. With activated quadriceps muscles (50 N), the contact area was 72.4 ± 45.9 mm2 in extension, 112.5 ± 54.9 mm2 in 15°flexion, and 286.1 ± 92.7 mm2 in 30°flexion without statistical significance. Postoperatively determined CCA revealed 159.3 ± 51.4 mm2 , 189.6 ± 62.2 mm2 and 347.3 ± 52.1 mm2 in 0°, 15° and 30°flexion. Quadriceps activation with 50 N showed acontact area in extension of 141.0 ± 63.8 mm2, 206.6 ± 67.7 mm2 in 15°flexion, and 353.5 ± 64.6 mm2 in 30°flexion, also without statistical difference compared with unloaded CCAs. Subjects with healthy knee joints showed an increase of 10.3% in CCA at 30°of flexion (p = 0.003). Although patellofemoral CCA increases significantly after isolated MPFL reconstruction in patients with low flexion patellofemoral instability, there is no significant influence of quadriceps muscles either preoperatively or postoperatively.

Patellofemoral joint disorders

Background: Patellofemoral joint problems refer to a spectrum of conditions affecting the patellofemoral joint, which is the joint between the patella and femur. These conditions can cause pain and instability in the knee and affect an individual’s ability to perform daily activities. Patellofemoral joint problems commonly cause knee pain, particularly among young athletes and physically active individuals. This review article discusses current patellofemoral joint problems, including their epidemiology, pathophysiology, diagnosis, and management.Current Concepts: Patellofemoral joint problems are presented as clinical symptoms of pain and instability. Dividing the diagnostic criteria into anterior knee pain, patella instability, and patellofemoral arthritis is useful. Anterior knee pain is diagnosed after excluding possible causes. Patellar instability is classified into recurrent dislocation, habitual dislocation (extension and flexion types), and permanent dislocation. Moreover, patellar instability can progress to the final stage of patellofemoral arthritis. Thus, patellar instability should be treated according to the Dejour criterion, and patellofemoral arthritis treatment requires artificial joint replacement surgery.Discussion and Conclusion: The pathological mechanism of patellofemoral joint problems still needs to be properly established, and multifactorial causes make it difficult to treat patellofemoral joint problems. Accurate diagnosis is considered an essential factor for successful treatment.

Clinical Insights into the Treatment of Patellofemoral Instability with Medial Patellofemoral Ligament Reconstruction: Pearls and Pitfalls-Lessons Learned from 20 Years.

Patellofemoral instability is a prevalent cause of pain and disability in young individuals engaged in athletic activities. Adolescents face a particularly notable risk of patellar dislocation, which can be attributed to rapid skeletal growth, changes in q-angle, ligamentous laxity, higher activity levels, and increased exposure to risk. Specific sports activities carry an elevated risk of patellar dislocation. Younger age and trochlear dysplasia present the highest risk factors for recurrent patellar dislocations. International guidelines recommend conservative therapy following a single patellar dislocation without osteochondral lesions but suggest surgical intervention in recurrent cases. In this study, we have compiled current scientific data on therapy recommendations, focusing on MPFL (medial patellofemoral ligament) reconstruction. We discuss patient selection, surgical indications, graft selection, location and choice of fixation, graft tensioning, and postoperative care.

Considerations on recurrent patella dislocation in the adolescent athlete

Recurrent patellar dislocation is described as loss of joint congruence between the femoral trochlea and the articular facet of the patella after a second episode. The etiology is multifactorial, including local, rotational and dynamic anatomical factors, and there is no clarity about its real influence, despite its high incidence and clinical importance. A search of Pubmed, Elsevier, Scielo, and Uptodate was conducted to identify recent articles on patellofemoral instability and recurrent patella dislocation. The pathogenic origin of recurrent patellar dislocation involves structural abnormalities, or muscle imbalances, its management is difficult, and multiple surgical techniques can be used. We recommend studying the possible causes and being consistent with them to carry out definitive treatment.

Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty

BackgroundRadiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or “favorable” bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. MethodsA consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. Results168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73–1.0). ConclusionWe demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.

The outcomes of constrained total hip arthroplasty for recurrent dislocation of hip hemiarthroplasty

IntroductionThe incidence of hemiarthroplasty dislocation for fracture neck of femurs ranges between 1 and 15% and the one-year mortality is 49- 70%. Revision of hemiarthroplasty to total hip replacement using a constrained liner has shown to improve the morbidity and mortality rates. The aim of the study was to assess whether conversion of dislocated hemiarthroplasty to total hip replacement improve functional and one year mortality. MethodsA retrospective analysis of the number of patients who had recurrent dislocations of hemiarthroplasty for fracture neck of femurs were carried out. The data were obtained from NHFD (National Hip Fracture Database) and internal hospital computer systems (Medway, Theatre notes and PACS) between Dec 2008 and Dec 2020. Patient demographics including age, sex, Abbreviated Mental Test Score (AMTS), functional assessment, mortality at one and two years were documented. The risk factors which led to dislocations such as Parkinsons disease, Cerebrovascular accidents, Musculo-neuropathies and Alzheimer`s disease was also noted. ResultsA total of 3994 patients were admitted during the study period of which 1735 (43.4%) patients had hemiarthroplasty. Fifty-six (3.23%) patients had dislocation of hemiarthroplasty. The mean age was 81.4 years (range – 61 to 95). There were 40 (71.4%) females and 16 males (28.6%). The average AMTS score was 5.3. All 56 patients had closed manipulative reduction under anaesthesia within in 12 h of admission. Thirty-one patients (55.4%) went on to have recurrent dislocations of which 18 patients (58.4%) had total hip replacement using captive cup, 6 patients (19.4%) had open reduction,3 patients (9.7%) had excision arthroplasty procedure and four patients (12.5%) had no intervention, Eighteen patients who had total hip replacement with constrained captive for followed up to a minimum of two years (range2- 12 years). There were no intraoperative complications, dislocation or periprosthetic fractures in the follow up period. There was no mortality at the end of two years of follow up in this group, two-year mortality for the patients with alternative management for dislocated hemiarthroplasty was 76.67. ConclusionTreatment of recurrent hemiarthroplasty dislocation by revising to a total hip replacement with a constrained liner gives good functional and mortality outcomes.

Arthroscopic posterior capsulolabral repair grants adequate outcomes in shoulders with posterior instability without glenoid cartilage lesions.

Posterior capsulolabral repair (posterior Bankart) is effective to restore shoulder stability and relieve pain, though a recent meta-analysis reported recurrent instability in 9.5% of patients, and that only 62.7% were able to resume sports. The purpose of this study was to assess the outcomes of arthroscopic posterior capsulolabral repair in a population of unselected patients, in terms of recurrence of instability, clinical scores, and return to sports. The authors retrospectively studied a consecutive series of 22 patients that underwent posterior capsulolabral repair between 2009 and 2019. Patients were assessed before posterior capsulolabral repair and at a minimum follow-up of 24months, in terms of subjective shoulder value (SSV), Western Ontario Shoulder Instability Index (WOSI), as well as level of sport. Following surgery, all complications, reoperations or episodes of instability were noted. The cohort comprised 21 men (95%) and 1 woman (5%), aged 38.8 ± 12.5years (range 17-61) at index surgery. Of the 20 patients that performed sports, only 2 (10%) stopped sports after surgery, while 18 resumed their main sport (90%). At a follow-up of 65.4 ± 34.8months (range 25-146), the SSV was 85.1 ± 14.7, pain on VAS was 1.9 ± 2.1, and the Constant-Murley score was 71.6 ± 17.9. Five patients had subjective instability without dislocation (23%). Nine patients (41%) had no pain (0 points), 6 patients (27%) had mild pain (1-2 points), 4 patients (18%) had moderate pain (3 points), while 3 patients (14%) had severe pain (5-8 points). Arthroscopic posterior capsulolabral repair prevented recurrent dislocation in patients with posterior shoulder instability at a minimum follow-up of 2years, despite persistent pain in 32%, and subjective instability in 23%. These complications were mainly observed in patients with work-related accidents and glenoid cartilage lesions. III, case series.