Recurrent Patellar Instability Research Articles

The Value of Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State for Commonly Used Patient-Reported Outcomes in Recurrent Patellar Instability Patients After Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer

To identify the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) for commonly used patient-reported outcomes (PROs) in recurrent patellar instability patients after medial patellofemoral ligament reconstruction (MPFLR) and tibial tubercle transfer (TTT), and to determine the impact of potential prognostic factors on the likelihood of achieving these values. From April 2015 to February 2021, patients who underwent MPFLR and TTT were retrospectively reviewed. PROs included Kujala, Knee Injury and Osteoarthritis Outcome (KOOS), Lysholm, International Knee Documentation Committee (IKDC) and Tegner score. Relevant anchor questions were provided. A distribution- or anchor-based method was adopted to determine the MCID, SCB and PASS. Minimal detectable change (MDC) was included to confirm the validity. Univariate regression analyses were conducted to determine the potential prognostic factors. 142 patients were included. The MCID were 9.1(Kujala), 11.1 (Lysholm), 0.9(Tegner), 9.9(IKDC), 9.0(KOOS-Pain), 10.8(KOOS-Symptoms), 10.0(KOOS-Activities of Daily Living (ADL)), 17.8(KOOS-Sports and Recreation (Sports/Rec)), and 12.7 (KOOS-Quality of Life (QoL)). The SCB were 14.5(Kujala), 12.5(Lysholm), 1.5(Tegner), 14.5(IKDC), 13.9(KOOS-Pain), 14.3(KOOS-Symptoms), 18.4(KOOS-ADL), 47.5(KOOS-Sports/Rec), 15.0(KOOS-QoL). The PASSs were 85.5(Kujala), 75.5(Lysholm), 3.5(Tegner), 73.2(IKDC), 87.5(KOOS-Pain), 73.2(KOOS-Symptoms), 92.0(KOOS-ADL), 77.5(KOOS-Sports/Rec), and 53.1(KOOS-QoL). All SCBs were valid except KOOS-QoL. All MCIDs were valid at the 95% confidence interval (CI) except KOOS scores, the majority of which were valid at the 90% CI. A younger age was an independent prognostic factor of reaching PASS for Lysholm, IKDC, Tegner and KOOS-ADL score. A higher baseline score was a negative prognostic factor for achieving MCID or SCB but had a slightly positive influence on the achievement of PASS. This study established the MCID, SCB, and PASS for commonly used PROs and confirmed their validity in recurrent patellar instability patients after MPFLR and TTT. Younger age and lower baseline scores were prognostic factors of achieving MCID and SCB, while patients with higher baseline scores were more likely to report satisfaction.

Poster 245: Clinical Measurement of the Standard Q-Angle Correlates Poorly with Tibial Tuberosity to Trochlear Groove Distance in Awake Patients and Anesthetized Patients with Patella Alta and Trochlear Dysplasia

Objectives: The quadriceps angle (Q-angle) measures the force vector of pull of the extensor mechanism of the knee. A larger Q-angle is thought to be a predisposing factor for patellar dislocation, but previous literature has reported poor reliability and validity of clinically measured Q-Angle. In response to poor reliability, a new “Standard Q-Angle” (SQA) was developed by Merchant et al. (Merchant 2020) in an attempt to create a standardized and repeatable method of clinically measuring the Q-Angle. The SQA may be a practical, inexpensive, and valuable part of physical examinations to help clinicians decide if concomitant medializing osteotomy is indicated in patellar stabilization procedures. However, SQA has not yet been validated in patients with anatomic risk factors for recurrent patellar instability such as patella alta and trochlear dysplasia. Furthermore, while SQA has previously been demonstrated to have strong interrater reliability, it has never been shown to correlate with standardized measurements for a lateralized tibial tuberosity, such as the Tibial Tuberosity – Trochlear Grove (TT-TG) distance. Therefore, the purpose of our study was to determine the correlation between SQA and TT-TG distance in patients with recurrent patellar instability. We hypothesized that there would be a positive correlation between SQA and TT-TG distance. 1. Merchant AC, Fraiser R, Dragoo J, Fredericson M. A reliable Q angle measurement using a standardized protocol. Knee. 2020;27(3):934-939. Methods: Patients at a single institution treated by a single surgeon with recurrent patellar instability who had previously obtained a dynamic 4D CT scan were included in this study. Patients who had previous patellar stabilization procedures were excluded. The Standard Q-angle was measured as previously described by Merchant et al. (Merchant 2020). The patient was placed in the supine position with the knee extended. A long-arm goniometer was centered over the patella with the distal arm over the tibial tuberosity and the proximal arm extended up to the anterior superior iliac spine (ASIS). The examiner then centered the patella within the trochlear groove and the SQA was measured. A second examiner stood at foot of the patient’s bed to confirm positioning. Measurements were taken in the office, as well as in the operating room after the induction of general anesthesia. All measurements were performed by the senior author (***). Utilizing 4D CT scans, the TT-TG, Caton-Deschamps index (CDI), and lateral trochlear inclination (LTI) were measured as previously described. Patients whose CDIs were between 0.8 and 1.2 were considered to have normal patellar height. Patients whose LTIs were >11° were considered to have normal LTI, which has been shown to have a sensitivity of 93% and a specificity 87% for detecting trochlear dysplasia. Mean and standard deviation values were calculated for patient demographic information, and correlation coefficients were calculated to compare SQA with TT-TG distance in both awake and anesthetized patients. The statistical software Stata was utilized for all analyses (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX). Results: Fifty-seven patient knees were included in the study. The mean age was 22 years-old (±6 years). For awake patients, the correlation coefficient (R2) between SQA and TT-TG was -0.006 (Figure 1), and in anesthetized patients R2 = 0.093 (Figure 2). In the “normal patellar height” group, the R2 value was higher in the anesthetized group (R2 = 0.334) than the awake group (R2 = 0.239). In the normal lateral trochlear inclination group, there was also a greater R2 value in the anesthetized group (R2 = 0.403) than the awake group (R2 =0.093). The correlation between SQA and TT-TG was the strongest in anesthetized patients with both a CDI < 1.2 and LTI >11° (R2 = 0.635). Conclusions: There was a strong positive association between SQA and TT-TG in anesthetized patients with normal patellar height and a normal lateral trochlear inclination. However, in awake patients and patients with anatomic risk factors for recurrent patellar instability there was only a weak association between SQA and TT-TG. The SQA may be able to provide useful information, but only in selected cases. Therefore, it remains important to have objective radiographic measurements to characterize the position of the tibial tuberosity when planning patellar stabilization surgery.

Poster 266: Outcomes of Surgical Stabilization for Recurrent Patellar Instability in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 6 years Mean Follow Up

Objectives: The purpose of this study was to assess return to play (RTP), patient-reported outcomes (PRO), and reoperation rates following patellofemoral stabilization surgeries (PSS) for recurrent patellar instability (RPI) in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of an RPI and subsequent PSS at a single institution between 2000 and 2020 were identified. Primary PSS ranged from MPFL reconstruction (n = 31; 50%) or MPFL repair (n = 22; 33.5%), and other PSS (n = 9; 14.5%) in the form of tibial tubercle osteotomy (TTO), lateral retinaculum release (LRR), and medial retinaculum reefing (MRR). Exclusion criteria included revision PSS, or concomitant anterior cruciate ligament reconstruction or multi ligament knee injury. All patients were contacted for determination of reinjury rates, current sport status, and PROs. Surgical failure defined as subsequent patellar dislocation despite operative management or need for secondary PSS. Results: Ultimately, 62 knees in 56 wrestlers were included at a mean follow-up time of 6.6 years (range, 2.0 – 18.8 years). RTP occurred in 55.3% of wrestlers at a mean of 8.8 ± 6.7 months. Among the PSS no differences were observed between rates of RTP (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). Recurrent patellar instability was the most common complication in 21% of knees. Among PSS types, MPFL reconstruction had the lowest rate of RPI (6.5% vs. 27.3% vs. 55.6%; P = .005), and surgical failure (9.7% vs. 31.8% vs. 55.6%; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared to MPFL repair and other PSS up to 10 years after the index surgery (90.3% vs. 64.1% vs. 27.8%; P = .048). Conclusions: Recurrent patellar instability remains a concern for competitive wrestlers after PSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared to other PSS up to 10 years after surgery. [Table: see text]

Lateral Opening Wedge Distal Femur Osteotomy and Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability

Background: A uniplanar, varus-producing distal femur osteotomy (DFO) may improve patellar tracking by effectively medializing the tibial tubercle, decreasing the Q-angle, and reducing the dislocation vector on the patella. Indications: A 17-year-old female with 8° of genu valgum presented with 18 months of symptomatic left knee patellar instability episodes that limit her function. Technique Description: A lateral subvastus approach to the distal femur was performed. Medial patellofemoral ligament reconstruction (MPFL-R) was conducted up to the point of femoral-sided graft fixation. A lateral opening wedge DFO was made with a sagittal saw and osteotomes, with care taken to maintain the medial cortical hinge. After distraction of the osteotomy site and femoral head allograft wedge placement, the osteotomy was secured with a lateral distal femoral locking plate. Finally, femoral-sided graft fixation for the MPFL-R was completed. Results: There were no immediate complications after surgery. Surgical management led to improvement of the patient's patellar instability, which allowed return to the prior baseline level of function. Discussion/Conclusion: The senior author's preferred technique for a lateral opening wedge DFO in association with an MPFL-R is presented. A varus-producing DFO is a surgical option for patients with genu valgum and recurrent patellar instability who have failed conservative management. This case demonstrates the efficacy of a lateral opening wedge DFO in improving patellar tracking and improving knee function by resolving recurrent patellar instability episodes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Poster 291: Ultrasound-based patellar glide test: A new dynamic assessment of patellar instability

Objectives: Patellar instability can be difficult to assess due to the dynamic nature of this condition. While MRI and CT can demonstrate the morphology of the patellofemoral joint, the assessment of instability relies on dynamic testing. The patellar glide test is commonly utilized as a method of dynamic assessment on physical examination, yet precise quantification with this method remains difficult. Recently, cadaveric studies have demonstrated the utility of ultrasound in quantifying patellar translation. Therefore, our study aimed to apply the ultrasound-based patellar glide test to determine its utility in differentiating between knees with and without patellar instability in a clinical population. Methods: Patients with recurrent patellar instability were included in this study. Using a portable device, the ultrasound-based patellar glide test was performed with the knee in extension, and patellar position was visualized with and without a manual lateralizing force. The ultrasound probe was placed at the medial patellofemoral joint to visualize the relation of the medial patellar facet to the medial trochlea. Descriptive statistics were used to describe patellar position in the unloaded and loaded states, and patellar translation was calculated as the difference between the loaded and unloaded positions. Values were compared between symptomatic and asymptomatic knees. For each measurement of translation, receiver operating characteristic (ROC) curve analysis was performed. Youden’s J statistic was calculated to determine the optimal cutoff values to distinguish between asymptomatic vs symptomatic knees. Results: 50 knees from 25 patients (17F, 8M, mean age 26.9+/-9.4) were included in this study, of which 29 knees were unstable and 21 were stable and asymptomatic. When comparing symptomatic and asymptomatic knees, patellar position in the unloaded (4.6+/-2.8mm vs 3.8+/-2.3mm, p=0.277) and loaded states (1.1+/-3.24mm, 2.1+/-2.5mm, p=0.252) were not significantly different. Patellar translation was found to be significantly different between the symptomatic and asymptomatic states (3.5+/-2.2mm vs 1.7+/-1.5mm, p=0.002). ROC curve analysis demonstrated that patellar translation >3mm detected the presence of patellar instability with AUC 0.88 (95% CI 0.77, 0.98). 3mm translation was found to identify patellar instability with sensitivity 43.4%, specificity 95.2%, PPV 90.9%, and NPV 60.6%. Conclusions: The ultrasound-based patellar glide test was found to differentiate between symptomatic and asymptomatic knees in patients with patellar instability with high accuracy. Given the increasing availability of portable ultrasound devices and the need for quantification of patellar laxity, further studies are recommended to evaluate the role of this method of assessment in the diagnosis and management of patellar instability.

Poster 269: 4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

Poster 269: 4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

Poster 284: Investigating the Frequency and Extent of Articular Cartilage Injury Following Patellar Dislocation: A Comparison of Recurrent vs. First-Time Dislocations

Objectives: In cases of patellar dislocation, surgical intervention is typically reserved for patients with recurrent instability, unless a chondral or osteochondral fragment is identified following the initial dislocation. There is concern that multiple dislocation events may result in a higher incidence of articular cartilage injury. The purpose of this study is to compare the incidence of articular cartilage damage in patients with a single patellar dislocation to those with multiple patellar dislocations, and secondarily to compare the location and severity of chondral injury between the groups. Methods: Patients diagnosed with patellar dislocation were retrospectively identified by ICD-9 & ICD-10 codes from 2017-2021. Inclusion criteria were patients with a documented history of patellar dislocation with an MRI of the affected knee available for review. Patients with articular cartilage injury prior to dislocation event were excluded. Medical records were reviewed to determine the number of previous patellar dislocations. Articular cartilage injury was graded using a validated system, AMADEUS (mean total Area Measurement And DEpth & Underlying Structures, a scale from 0 to 100; 100 = no injury). Parametric continuous data was calculated by performing t tests. Nonparametric continuous data was calculated by performing Mann-Whitney tests. Chi-Square or Fisher’s Exact tests were used to calculate p values for categorical data. Results: After chart and imaging review, 233 patients were included: 117 with a primary dislocation and 116 with recurrent dislocations. Fifty-one (43.6%) of the primary dislocations and 68 (58.6%) of the recurrent dislocations were found to have articular cartilage injuries (p=0.068). When comparing the primary and recurrent groups, there was no difference in age, BMI, race, or laterality, but the recurrent group contained a significantly larger proportion of females (46.2% vs. 65.5%, P=0.004). There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between groups (p=0.231). Subgroup analysis revealed that when cartilage damage is present, patients from the primary group had significantly more full-thickness lesions (p<0.001) and lower AMADEUS scores (p=0.016). The primary group had an increased proportion of medial facet and lateral femoral condyle lesions (p=0.026). Conclusions: There is a high percentage of cartilage injury in patients with a history of primary and recurrent patellar instability, with 43.6% and 58.6% of patients respectively, showing articular cartilage injury on MRI. Chondral injury primarily affected the medial and lateral patellar facets, and the lateral femoral condyle in both the primary and recurrent dislocation groups. However, the primary group demonstrated an increased number of full thickness lesions and subchondral bone defects. There was no difference in lesion size, presence of bone edema, or total AMADEUS score between the primary and recurrent groups. [Table: see text][Table: see text]

Differences in the Severity and Location of Patellofemoral Cartilage Damage Between Instability Patients With and Without Patella Alta.

Patella alta is a risk factor for recurrent patellar instability. Differences in chondral injury in patients with patellar instability between patella alta and patella norma have not been evaluated. To analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta. Cohort study; Level of evidence, 3. Patients with patellar instability who underwent patellar realignment surgery at a single institution with preoperative magnetic resonance imaging (MRI) scans were included. After measurement of Caton-Deschamps index (CDI) on MRI, patients were divided into patella alta (CDI ≥1.3) and patella norma groups. The area measurement and depth and underlying structures (AMADEUS) score was used to quantify cartilage defect severity on MRI. A total of 121 patients were divided into patella alta (n = 50) and patella norma (n = 71) groups. The groups did not differ significantly in sex ratio, age at MRI, body mass index, mean reported number of previous dislocations, or mean interval between first reported dislocation and date of MRI. A total of 34 (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects (P = .625) with no significant between-group differences in defect size (P = .419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%). A smaller proportion of patients had full-thickness defects in the patella alta compared with the patella norma group (60% vs 82%; P = .030). The overall AMADEUS score was higher for the patella alta versus the patella norma group (68.9 vs 62.1; P = .023), indicating superior articular cartilage status. Patients with patella alta had less severe cartilage injury after patellar instability, including a lower proportion with full-thickness defects and better overall cartilage grade. The location of injury when present was similar between alta and norma, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency.

Surgical Stabilization for Recurrent Patellar Instability in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 6-Year Mean Follow-up

Background: The extent to which recurrent patellar instability (RPI) affects wrestlers has not been thoroughly examined. Purpose: To assess return to wrestling (RTW), patient-reported outcomes, and reoperation rates after patellofemoral stabilization surgery (PFSS) for RPI in a cohort of competitive wrestlers. Study Design: Cohort study; Level of evidence, 3. Methods: All competitive wrestlers with a history of RPI and subsequent PFSS performed at a single institution between 2000 and 2020 were identified. Primary PFSS procedures included medial patellofemoral (MPFL) reconstruction (n = 31; 50%); MPFL repair (n = 22; 35.5%); or other PFSS (n = 9; 14.5%), such as tibial tubercle osteotomy, lateral retinacular release, and/or medial retinacular reefing. Exclusion criteria included revision PFSS or concomitant anterior cruciate ligament reconstruction or multiligament knee injury. Surgical failure was defined as subsequent patellar dislocation despite operative management or need for secondary PFSS. Results: Ultimately, 62 knees in 56 wrestlers with a mean age of 17.0 years (range, 14.0-22.8 years) were included at a mean follow-up of 6.6 years (range, 2.0-18.8 years). RTW occurred in 55.3% of wrestlers at a mean ± SD 8.8 ± 6.7 months. Among PFSS types, no differences were observed in rates of RTW (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). RPI was the most common postoperative complication (n = 13; 21.0%). MPFL reconstruction had the lowest rate of RPI (6.5% vs 27.3% [repair] vs 55.6% [other]; P = .005) and surgical failure (9.7% vs 31.8% [repair] vs 55.6% [other]; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared with MPFL repair and other PFSS up to 10 years after the index surgery (90.3% vs 64.1% vs 27.8%; P = .048). Conclusion: RPI remains a concern for competitive wrestlers after PFSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared with other PFSS procedures at up to 10 years after surgery.

Translated article] Total knee arthroplasty is effective in patients with Parkinson's disease. Functional assessment and analysis of complications

IntroductionThanks to improvements in the medical treatment of Parkinson's disease (PD), the life expectancy of these patients has increased, but the overall outcome after total knee arthroplasty (TKA) is controversial. We aim to analyse a series of patients with PD, evaluating their clinical status, functional results, complications and survival rates after TKA. MethodsWe retrospectively studied 31 patients with PD operated between 2014 and 2020. The mean age was 71 years (SD±5.8). There were 16 female patients. The mean follow-up was 68.2 months (SD±36). We used the knee scoring system (KSS) and the visual analogue scale (VAS) for the functional evaluation. The modified Hoehn and Yahr scale was used to assess the severity of PD. All complications were recorded, and survival curves were performed. ResultsThe mean postoperative KSS evaluation had an increase of 40 points [35 (SD±15) vs 75 (SD±15) (p<.001)]. The mean postoperative VAS decreased 5 points [8 (SD±2) vs 3 (SD±2) (p<.001)]. Thirteen patients reported being very satisfied, 13 were satisfied, and only 5 were poorly satisfied. Seven patients suffered surgical complications, and 4 patients had recurrent patellar instability. At a mean 68.2 months follow-up, the overall survival rate was 93.5%. When considering the secondary patellar resurfacing as the endpoint, the survival rate was 80.6%. ConclusionsIn this study, TKA was associated with excellent functional outcomes in patients with PD. At a mean 68.2 months follow-up, TKA had excellent survivorship in the short term, with recurrent patellar instability as the most common complication. Even though these findings confirm the effectiveness of TKA in this population, a thorough clinical evaluation and multidisciplinary approach are needed to decrease the likelihood of complications.

Long-Term Follow-Up of the Roux-Goldthwait Patellar Stabilization Procedure in a Predominantly Adult Population.

Background The Roux-Goldthwait patellar stabilisation (R-G) involves the medial transfer of the distal attachment of the lateral half of the patellar tendon. This paper reviews the long-term results of the R-G in a predominantly adult population. Methodology This is a retrospective study looking at patients with recurrent patellar instability who were treated with an R-G technique by a single surgeon over a 36-year period from 1976 to 2012. The primary outcomes measured werefurther patella instability andfurther knee surgical procedures. Results A total of 202 knees in 170 patients were analysed in this study. Patients between the ages of 9 and 70 years old (average 21 years old) were included in this study. The operative procedure changed during the study period. Initially, patients did not undergo concurrent arthroscopy. Early patients were likely to have additional lateral releases and open medial reefing procedures. More recent patients were more likely to undergo an isolated R-G procedure via a minimally invasive incision. The most common further operative procedure was arthroscopy of the knee for chondral pathology at 13.9%. These were more common early in the study period when patients did not have an initial arthroscopy. Recurrent dislocation was reported at 12.9%, with 5.9% of patients having revision stabilisation surgery, at a mean of 5.58 years (range = 1-15 years) postoperatively. Conclusions The R-G procedure is effective in treating recurrent patellar instability in both the paediatric and adult population. It can be performed as an isolated and minimally invasive procedure which is technically simple and has low morbidity.

Feasibility of Return to Sports Readiness Assessment at 6 months after Surgery for Recurrent Patellar Instability

Feasibility of Return to Sports Readiness Assessment at 6 months after Surgery for Recurrent Patellar Instability

The Epidemiology of Surgical Procedures for Recurrent Patellar Instability in the Jupiter Cohort

The Epidemiology of Surgical Procedures for Recurrent Patellar Instability in the Jupiter Cohort

Medial patellofemoral ligament reconstruction and tibial tuberosity transfer can be used to successfully manage patellofemoral instability in the setting of trochlea dysplasia

BackgroundManagement of patella instability remains a challenge particularly in the presence of trochlea dysplasia. The aim of this study is to assess the recurrence rates of those with patellar instability who have undergone a combined tibial tuberosity transfer (TTT) and medial patellofemoral ligament reconstruction (MPFLR) in the setting of trochlea dysplasia.MethodsAll skeletally mature patients who underwent combined TTT and MPFLR for recurrent patella instability were identified between January 2009 and December 2019. A retrospective review was conducted, with information regarding re-dislocation/subluxation and complications collected.ResultsSeventy patients with a mean age 25.3 years were identified and evaluated. Thirteen patients were found to have low-grade dysplasia (Dejour A), with 57 patients having high-grade dysplasia (Dejour B/C/D). No patients in the low,grade dysplasia group suffered a recurrence of their symptoms, with four in the high-grade group suffering episodes of re-dislocation/subluxation. Three patients subsequently underwent a trochleoplasty, with the other patient managed successfully non-operatively. There were a total of 13 complications in 11 patients.ConclusionsA combined procedure of MPFLR and TTT can be used to manage patellofemoral instability even in the setting of trochlea dysplasia with a low rate of recurrence. Trochlea dysplasia, however, remains an anatomical risk factor for recurrence and patients should be counselled accordingly. The anatomical risk factors should be assessed in all patients to allow for the development of the most appropriate management plan, of which this combined procedure represents a potentially successful option.Level of EvidenceIV (Case Series).

Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index.

Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes. This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting. A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30kg/m2 (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30kg/m2 (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found. BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21. Level III.

La artroplastia total de rodilla en pacientes con enfermedad de Parkinson es efectiva. Evaluación funcional y análisis de complicaciones

IntroductionThanks to improvements in the medical treatment of Parkinson's disease (PD), the life expectancy of these patients has increased, but the overall outcome after total knee arthroplasty (TKA) is controversial. We aim to analyse a series of patients with PD, evaluating their clinical status, functional results, complications and survival rates after TKA. MethodsWe retrospectively studied 31 patients with PD operated between 2014-2020. The mean age was 71 years (SD±5.8). There were 16 female patients. The mean follow-up was 68.2 months (SD±36). We used the Knee Scoring System (KSS) and the Visual Analog Scale (VAS) for the functional evaluation. The Modified Hoehn and Yahr Scale was used to assess the severity of PD. All complications were recorded, and survival curves were performed. ResultsThe mean postoperative KSS evaluation had an increase of 40 points [35 (SD±15) vs 75 (SD±15) (P<.001)]. The mean postoperative VAS decreased 5 points [8 (SD±2) vs 3 (SD±2) (P<.001)]. Thirteen patients reported being very satisfied, 13 were satisfied, and only 5 were poorly satisfied. Seven patients suffered surgical complications, and 4 patients had recurrent patellar instability. At a mean 68.2 months follow-up, the overall survival rate was 93.5%. When considering the secondary patellar resurfacing as the endpoint, the survival rate was 80.6%. ConclusionsIn this study, TKA was associated with excellent functional outcomes in patients with PD. At a mean 68.2 months follow-up, TKA had excellent survivorship in the short term, with recurrent patellar instability as the most common complication. Even though these findings confirm the effectiveness of TKA in this population, a thorough clinical evaluation and multidisciplinary approach are needed to decrease the likelihood of complications.

Strategie léčby a vyhodnocení výsledků operací recidivujících patelárních nestabilit mezi roky 2010-2020

Strategie léčby a vyhodnocení výsledků operací recidivujících patelárních nestabilit mezi roky 2010-2020

Children’s orthopaedics

The February 2023 Children’s orthopaedics Roundup360 looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Medial Patellofemoral Ligament Reconstruction using Semitendinosus and Gracilis Autograft with Anteromedialization of Tibial Tuberosity for Recurrent Patellar Instability: A Case Report

Medial patellofemoral ligament reconstruction is used to treat a substantial and recurring dislocation of the knee cap. Recurrent patellar instability is common in children, teenagers and young adult. A 20-year-old female presented with a five-year history of left knee pain. The clinical examination reveals that apprehension test is positive; there is pain and muscle defensive contraction of lateral patellar dislocation with knee flexion of 20°-30°. The X-ray shows a double contour sign, crossing sign, laterally tilted patella with flattened trochlear joint surface. The patient underwent medial patellofemoral ligament reconstruction using semitendinosus and gracilis tendon autograft with anteromedialization of tibial tuberosity. The patient is able to resume normal daily activities without complaint following the operation.

4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children.

Habitual and fixed patellar dislocations represent extreme forms of patellar instability and can lead to significant functional loss. The underlying complex pathoanatomy of a laterally positioned and shortened extensor mechanism poses challenges in its management. The purpose of our study was to evaluate the anatomic risk factors and outcomes of a 4-in-1 quadricepsplasty (wide lateral releases, Insall proximal tube realignment, Roux-Goldthwait patellar tendon hemi-transfer, and step-wise quadriceps lengthening) for stabilization of habitual and fixed patellar dislocation. In a retrospective study, all patients with habitual and fixed patellar dislocation who underwent 4-in-1 quadricepsplasty and had a minimum 2-year follow-up were identified. Preoperative magnetic resonance imagings were evaluated for the presence of anatomic risk factors. As a prospective part of the study, patient-reported outcomes were collected using validated instruments including Pedi-IKDC, HSS-Pedi FABS activity score, BPII 2.0 score, Kujala score, and KOOS score. Seventeen knees (12 patients) formed the study cohort. Twelve knees had habitual dislocation (9 in extension and 4 in flexion) and 5 had fixed dislocation. Mean age was 9 years. 6/17 (35.3%) knees were associated with syndromes. On magnetic resonance imaging, trochlear dysplasia was the most common anatomic risk factor present in 15/17 (88.2%) knees. 13/17 (76%) knees had presence of 2 or more risk factors. At the mean follow-up of 43.3 months, the mean Pedi-IKDC score was 88.1, the HSS-Pedi FABS activity score was 15.6, the BPII 2.0 score was 78.2, the Kujala score was 90, KOOS score was 93.9, and overall patient satisfaction score was 83.3. For complications, 3/17 knees (17.6%) had recurrent patellar instability, 1 knee had postoperative stiffness that required manipulation under anesthesia and 1 knee had a superficial wound infection. Most patients with habitual and fixed patellar dislocation present during the first decade of life. There are several underlying anatomic risk factors, the most common being trochlear dysplasia and patellar tilt. The 4-in-1 quadricepsplasty technique provides reliable patellar stabilization, satisfactory clinical results, and acceptable patient-reported outcomes at a minimum 2-year follow-up, with a 17.6% redislocation rate. Level IV.